1
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Balan S, Madan S. Idiopathic Inflammatory Myopathies. Indian J Pediatr 2023:10.1007/s12098-023-04896-z. [PMID: 37919486 DOI: 10.1007/s12098-023-04896-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Abstract
Idiopathic inflammatory myopathies (IIMs) are a diverse group of diseases characterized by proximal muscle weakness and inflammation in skeletal muscle. Phenotypically, the subtypes include dermatomyositis, polymyositis, inclusion body myositis, and amyopathic dermatomyositis. The most common IIM in children is juvenile dermatomyositis (JDM). In contrast to adult dermatomyositis (DM), children are likely to have frequent relapses, vasculopathy, and long-term metabolic and other complications like lipodystrophy, insulin resistance, and calcinosis. Significant advances in our understanding of pathogenesis, disease course, and treatment of JDM has changed the therapeutic landscape and improved outcomes in children. Myositis-specific autoantibodies and myositis-associated autoantibodies have unique clinical associations, disease course and help predict response to therapy. A multidisciplinary approach including exercise programs and psychosocial support is essential. The first line of treatment is a combination of corticosteroids and methotrexate (MTX). Other targeted immunosuppressive therapy is used in refractory cases. Early recognition and timely referral to a specialist center remain pivotal to improving the mortality and morbidity associated with this disease.
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Affiliation(s)
- Suma Balan
- Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences and Research Centre, Ponekkara, Kochi, Kerala, 682 041, India.
| | - Sumanth Madan
- Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences and Research Centre, Ponekkara, Kochi, Kerala, 682 041, India
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2
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Muddebihal A, Khurana A, Sardana K. Cyclophosphamide in a Recalcitrant Case of Nekam's Disease. Dermatol Pract Concept 2023; 13:e2023154. [PMID: 37557153 PMCID: PMC10412009 DOI: 10.5826/dpc.1303a154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 08/11/2023] Open
Affiliation(s)
- Aishwarya Muddebihal
- Department of Dermatology Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Ananta Khurana
- Department of Dermatology Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
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3
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Papadopoulou C, Chew C, Wilkinson MGL, McCann L, Wedderburn LR. Juvenile idiopathic inflammatory myositis: an update on pathophysiology and clinical care. Nat Rev Rheumatol 2023; 19:343-362. [PMID: 37188756 PMCID: PMC10184643 DOI: 10.1038/s41584-023-00967-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 05/17/2023]
Abstract
The childhood-onset or juvenile idiopathic inflammatory myopathies (JIIMs) are a heterogenous group of rare and serious autoimmune diseases of children and young people that predominantly affect the muscles and skin but can also involve other organs, including the lungs, gut, joints, heart and central nervous system. Different myositis-specific autoantibodies have been identified that are associated with different muscle biopsy features, as well as with different clinical characteristics, prognoses and treatment responses. Thus, myositis-specific autoantibodies can be used to subset JIIMs into sub-phenotypes; some of these sub-phenotypes parallel disease seen in adults, whereas others are distinct from adult-onset idiopathic inflammatory myopathies. Although treatments and management have much improved over the past decade, evidence is still lacking for many of the current treatments and few validated prognostic biomarkers are available with which to predict response to treatment, comorbidities (such as calcinosis) or outcome. Emerging data on the pathogenesis of the JIIMs are leading to proposals for new trials and tools for monitoring disease.
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Affiliation(s)
- Charalampia Papadopoulou
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH), London, UK
- Rare Diseases Theme NIHR Biomedical Research Centre at GOSH, London, UK
| | - Christine Chew
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Meredyth G Ll Wilkinson
- Rare Diseases Theme NIHR Biomedical Research Centre at GOSH, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, London, UK
- Infection Immunity and Inflammation Research and Teaching Department, UCL GOS Institute of Child Health, London, UK
| | - Liza McCann
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Lucy R Wedderburn
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH), London, UK.
- Rare Diseases Theme NIHR Biomedical Research Centre at GOSH, London, UK.
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, London, UK.
- Infection Immunity and Inflammation Research and Teaching Department, UCL GOS Institute of Child Health, London, UK.
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4
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Wilkinson MGL, Moulding D, McDonnell TCR, Orford M, Wincup C, Ting JYJ, Otto GW, Restuadi R, Kelberman D, Papadopoulou C, Castellano S, Eaton S, Deakin CT, Rosser EC, Wedderburn LR. Role of CD14+ monocyte-derived oxidised mitochondrial DNA in the inflammatory interferon type 1 signature in juvenile dermatomyositis. Ann Rheum Dis 2023; 82:658-669. [PMID: 36564154 PMCID: PMC10176342 DOI: 10.1136/ard-2022-223469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/01/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To define the host mechanisms contributing to the pathological interferon (IFN) type 1 signature in Juvenile dermatomyositis (JDM). METHODS RNA-sequencing was performed on CD4+, CD8+, CD14+ and CD19+ cells sorted from pretreatment and on-treatment JDM (pretreatment n=10, on-treatment n=11) and age/sex-matched child healthy-control (CHC n=4) peripheral blood mononuclear cell (PBMC). Mitochondrial morphology and superoxide were assessed by fluorescence microscopy, cellular metabolism by 13C glucose uptake assays, and oxidised mitochondrial DNA (oxmtDNA) content by dot-blot. Healthy-control PBMC and JDM pretreatment PBMC were cultured with IFN-α, oxmtDNA, cGAS-inhibitor, TLR-9 antagonist and/or n-acetyl cysteine (NAC). IFN-stimulated gene (ISGs) expression was measured by qPCR. Total numbers of patient and controls for functional experiments, JDM n=82, total CHC n=35. RESULTS Dysregulated mitochondrial-associated gene expression correlated with increased ISG expression in JDM CD14+ monocytes. Altered mitochondrial-associated gene expression was paralleled by altered mitochondrial biology, including 'megamitochondria', cellular metabolism and a decrease in gene expression of superoxide dismutase (SOD)1. This was associated with enhanced production of oxidised mitochondrial (oxmt)DNA. OxmtDNA induced ISG expression in healthy PBMC, which was blocked by targeting oxidative stress and intracellular nucleic acid sensing pathways. Complementary experiments showed that, under in vitro experimental conditions, targeting these pathways via the antioxidant drug NAC, TLR9 antagonist and to a lesser extent cGAS-inhibitor, suppressed ISG expression in pretreatment JDM PBMC. CONCLUSIONS These results describe a novel pathway where altered mitochondrial biology in JDM CD14+ monocytes lead to oxmtDNA production and stimulates ISG expression. Targeting this pathway has therapeutical potential in JDM and other IFN type 1-driven autoimmune diseases.
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Affiliation(s)
- Meredyth G Ll Wilkinson
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, UCL, London, UK
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
| | - Dale Moulding
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
- Developmental Biology and Cancer Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Thomas C R McDonnell
- Centre for Rheumatology Research, Division of Medicine, University College London, London, UK
| | - Michael Orford
- Developmental Biology and Cancer Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Chris Wincup
- Centre for Rheumatology Research, Division of Medicine, University College London, London, UK
| | - Joanna Y J Ting
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Georg W Otto
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
- Experimental and Personalised Medicine, Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
- Genetics and Genomic Medicine Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Restuadi Restuadi
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, UCL, London, UK
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
| | - Daniel Kelberman
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
- Experimental and Personalised Medicine, Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
- Genetics and Genomic Medicine Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Charalampia Papadopoulou
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Rheumatology, Great Ormond Street Hospital NHS Trust, London, UK
| | - Sergi Castellano
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
- Genetics and Genomic Medicine Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Simon Eaton
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
- Developmental Biology and Cancer Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Claire T Deakin
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, UCL, London, UK
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
| | - Elizabeth C Rosser
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, UCL, London, UK
- Centre for Rheumatology Research, Division of Medicine, University College London, London, UK
| | - Lucy R Wedderburn
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, UCL, London, UK
- NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
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5
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Patil A, Lu J, Kassir M, Babaei M, Goldust M. Adult and juvenile dermatomyositis treatment. J Cosmet Dermatol 2023; 22:395-401. [PMID: 36065712 DOI: 10.1111/jocd.15363] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/17/2022] [Accepted: 09/02/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Dermatomyositis is a rare autoimmune inflammatory condition affecting skin and muscles. The disease can be seen in both adults and children. It can be associated with malignancy. Considering involvement of skin in the disease, many patients consult dermatologists for its treatment. Hence, knowledge about its presentation, complications, prognosis, and treatment is necessary. OBJECTIVE The objective of this review article is to provide comprehensive information about treatment of dermatomyositis. METHODS In this review article, we reviewed the published literature on adult and juvenile dermatomyositis to highlight the treatment. Articles published in peer-reviewed journals including reviews, clinical trials, case series, and case reports published in electronic database (MEDLINE/PubMed) through January 2021, cross references of respective articles and trials from clinicaltrials.gov were included for qualitative analysis of the literature. RESULTS Treatment options for dermatomyositis include traditional immunosuppressive agents and immunomodulatory therapy. High-dose corticosteroids represent the first line of treatment while other immunosuppressive agents are also used, either in combination with or as an alternative to corticosteroids, after initial treatment failure. Some biological agents have been used for the treatment of dermatomyositis with variable responses. CONCLUSION Although several treatment options are available, several questions remain unanswered about the optimal treatment of dermatomyositis.
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Affiliation(s)
- Anant Patil
- Department of Pharmacology, Dr. DY Patil Medical College, Navi Mumbai, India
| | - Jun Lu
- UConn Health Department of Dermatology, Farmington, Connecticut, USA
| | | | - Mahsa Babaei
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohamad Goldust
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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6
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Melo AT, Dourado E, Campanilho-Marques R, Bandeira M, Barreira SC, Costa J, Pimenta R, Antunes-Duarte S, Cordeiro I, Fonseca JE. Myositis Multidisciplinary Clinic in a Tertiary Referral Center. J Multidiscip Healthc 2023; 16:1127-1139. [PMID: 37131932 PMCID: PMC10149065 DOI: 10.2147/jmdh.s404017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/28/2023] [Indexed: 05/04/2023] Open
Abstract
Background Idiopathic inflammatory myopathies (IIM) are a rare heterogeneous group of diseases characterised by chronic skeletal muscle inflammation, but other organs are also frequently involved. IMM represent a diagnostic challenge and a multidisciplinary approach is important to ensure successful diagnosis and adequate follow-up of these patients. Objective To describe the general functioning of our multidisciplinary myositis clinic, highlighting the benefits of multidisciplinary team management in patients with confirmed or suspected IIM and to characterise our clinical experience. Methods Description of the organization of a dedicated multidisciplinary myositis outpatient clinic, supported by IMM specific electronic assessment tools and protocols based on our Portuguese Register - Reuma.pt. In addition, an overview of our activity between 2017 and 2022 is provided. Results An IIM multidisciplinary care clinic, based on a close collaboration between Rheumatologists, Dermatologists and Physiatrist is detailed in this paper. One hundred and eighty-five patients were assessed in our myositis clinic; 138 (75%) of those were female, with a median age of 58 [45-70] years. At the last appointment, 130 patients had a confirmed IIM diagnosis, and the mean disease duration was 4 [2-6] years. The most frequent diagnosis was dermatomyositis (n = 34, 26.2%), followed by antisynthetase syndrome (n = 27, 20.8%) and clinically amyopathic/paucimyopathic dermatomyositis (n = 18, 13.8%). Twenty-four patients (18.5%) were on monotherapy and 94 (72.3%) were on combination therapy. Conclusion A multidisciplinary approach is important to ensure the correct diagnosis and follow-up of these patients. A myositis clinic, with a standardised practice at a tertiary hospital level, contributes to a standardization of care and opens research opportunities.
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Affiliation(s)
- Ana Teresa Melo
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Correspondence: Ana Teresa Melo, Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, EPE, R. Prof. Egas Moniz, Lisboa, 1700, Portugal, Tel +351 217805139, Email
| | - Eduardo Dourado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Raquel Campanilho-Marques
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Matilde Bandeira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Sofia C Barreira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - José Costa
- Physical Medicine and Rehabilitation Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Rita Pimenta
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Sofia Antunes-Duarte
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Inês Cordeiro
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - João E Fonseca
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
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7
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Wang CH, Liang WC. Pediatric immune-mediated necrotizing myopathy. Front Neurol 2023; 14:1123380. [PMID: 37021281 PMCID: PMC10067916 DOI: 10.3389/fneur.2023.1123380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/03/2023] [Indexed: 04/07/2023] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a type of inflammatory myopathy. Most patients with IMNM produce anti-3-hydroxy-3-methylglutaryl coenzyme A reductase or anti-signal-recognition particle autoantibodies. IMNM is much rarer in children than in adults. We conducted this mini review focusing on pediatric IMNM to present current evidence regarding its epidemiology, clinical characteristics, diagnosis, and treatment. Our findings indicate that pediatric IMNM often causes severe muscle weakness and is refractory to corticosteroids alone. Furthermore, delayed diagnosis is common because of the clinicopathological similarity between IMNM and inherited myopathy. Raising awareness regarding pediatric IMNM may facilitate early diagnosis and effective treatment.
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Affiliation(s)
- Chen-Hua Wang
- Department of Pediatrics, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Wen-Chen Liang,
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8
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Juvenile Dermatomyositis With Macrophage Activation and Severe Encephalopathy. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2606-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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9
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Oldroyd AGS, Lilleker JB, Amin T, Aragon O, Bechman K, Cuthbert V, Galloway J, Gordon P, Gregory WJ, Gunawardena H, Hanna MG, Isenberg D, Jackman J, Kiely PDW, Livermore P, Machado PM, Maillard S, McHugh N, Murphy R, Pilkington C, Prabu A, Rushe P, Spinty S, Swan J, Tahir H, Tansley SL, Truepenny P, Truepenny Y, Warrier K, Yates M, Papadopoulou C, Martin N, McCann L, Chinoy H. British Society for Rheumatology guideline on management of paediatric, adolescent and adult patients with idiopathic inflammatory myopathy. Rheumatology (Oxford) 2022; 61:1760-1768. [PMID: 35355064 PMCID: PMC9398208 DOI: 10.1093/rheumatology/keac115] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 02/21/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alexander G S Oldroyd
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK.,Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
| | - James B Lilleker
- Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Tania Amin
- Department of Paediatric Rheumatology, Leeds Children's Hospital, Leeds, UK
| | - Octavio Aragon
- Pharmacy Department, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.,School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Verna Cuthbert
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Patrick Gordon
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - William J Gregory
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK.,Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Harsha Gunawardena
- Department of Rheumatology, North Bristol NHS Trust, Bristol, UK.,Department of Clinical and Academic Rheumatology, University of Bristol, Bristol, UK
| | - Michael G Hanna
- Queen Square Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - David Isenberg
- Department of Rheumatology, Division of Medicine, University College London, London, UK
| | - John Jackman
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford, UK
| | - Patrick D W Kiely
- Department of Rheumatology, St George's University Hospitals NHS Foundation Trust, London, UK.,Institute of Medical and Biomedical Education, St George's, University of London, London, UK
| | - Polly Livermore
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK.,NIHR Great Ormond Street and University College London Biomedical Research Centre, London, UK
| | - Pedro M Machado
- Department of Neuromuscular Diseases, Centre for Rheumatology, University College London, London, UK.,NIHR University College London Hospitals Biomedical Research Centre, University College London Hospitals (UCLH) NHS Foundation Trust, London, UK.,Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Sue Maillard
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Neil McHugh
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Ruth Murphy
- Department of Dermatology, Sheffield University Teaching Hospitals, Sheffield, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Athiveeraramapandian Prabu
- Rheumatology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Stefan Spinty
- Department of Paediatric Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Joanne Swan
- Juvenile Dermatomyositis Parent Representative
| | - Hasan Tahir
- Department of Rheumatology, Royal Free London NHS Trust, London, UK.,Division of Medicine, University College London, London, UK
| | - Sarah L Tansley
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.,Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | | | | | - Kishore Warrier
- Department of Paediatric Rheumatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Charalampia Papadopoulou
- Department of Paediatric Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Neil Martin
- Department of Paediatric Rheumatology, Royal Hospital for Children, Glasgow, UK.,Scottish Paediatric & Adolescent Rheumatology Network, Glasgow, Scotland
| | - Liza McCann
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Hector Chinoy
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
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10
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Hinze C, Dressler F, Schara-Schmidt U, Haas JP. Juvenile Dermatomyositis. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1769-4299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDie juvenile Dermatomyositis (JDM) ist die häufigste chronische
entzündliche Myopathie des Kindesalters. In dieser Übersicht
soll der aktuelle Kenntnisstand hinsichtlich der Diagnostik, Behandlung und
Überwachung der JDM dargestellt werden. So liegen häufig
myositis-spezifische Antikörper vor, die mit klinischen
Phänotypen und dem Verlauf der Erkrankung korrelieren. Typ I Interferone
spielen eine wichtige Rolle in der Pathogenese der Erkrankung.
Möglicherweise kann diese Beobachtung in der Zukunft zu gezielten
Therapien führen. Da langfristig schwerwiegende Komplikationen, wie
z. B. Kalzinosen oder Lipodystrophie, drohen, besonders bei auf Dauer
unzureichend kontrollierter Erkrankung, ist eine möglichst rasche und
effektive Behandlung anzustreben. Zu diesem Zweck sollte eine intensive
Remissionsinduktionstherapie, gefolgt von einer zielgerichteten Therapie
angestrebt werden. Verschiedene validierte Messinstrumente stehen zur
Verfügung, um den Verlauf der Erkrankung zu beurteilen. Die
Pro-KIND-Initiative der Gesellschaft für Kinder- und Jugendrheumatologie
hat Praxis- und Konsens-basiert in Deutschland sowohl eine diagnostische als
auch eine Treat-to-Target-Behandlungsstrategie entwickelt. Im Rahmen nationaler
und internationaler Kollaborationen soll sich die Behandlung der JDM in der
Zukunft weiter verbessern.
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Affiliation(s)
- Claas Hinze
- Klinik für Pädiatrische Rheumatologie und Immunologie,
Universitätsklinikum Münster, Münster,
Germany
| | - Frank Dressler
- Klinik für Pädiatrische Pneumologie, Allergologie und
Neonatologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Ulrike Schara-Schmidt
- Abteilung für Neuropädiatrie, Zentrum für
Neuromuskuläre Erkrankungen im Kindes- und Jugendalter,
Universitätsklinikum Essen, Essen, Germany
| | - Johannes-Peter Haas
- German Center for Rheumatology in Children and Adolescents, Deutsches
Zentrum für Kinder- und Jugendrheumatologie Garmisch-Partenkirchen,
Garmisch-Partenkirchen, Germany
- Center for treatment of pain in young people, Zentrum für
Schmerztherapie junger Menschen, Garmisch-Partenkirchen, Germany
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11
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Rhim JW. Juvenile Dermatomyositis. JOURNAL OF RHEUMATIC DISEASES 2022; 29:14-21. [PMID: 37476697 PMCID: PMC10324917 DOI: 10.4078/jrd.2022.29.1.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 07/22/2023]
Abstract
Juvenile dermatomyositis (JDM) is a systemic capillary vasculopathy. Patients present with proximal muscle weakness, raised muscle enzymes, and pathognomic skin rashes such as heliotrope rash, Gottron's papules. Main complications are calcinosis, lipodystrophy, osteoporosis. Complement-mediated damage of vessels is a major mechanism. Magnetic resonance imaging is currently widely used to diagnosis of JDM. The goals of treatment are to control inflammatory myositis and prevent disease complication. Early, aggressive treatment of JDM associated with a better prognosis. High-dose corticosteroids in combination with methotrexate is the mainstay of treatment. The course of JDM is variable.
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Affiliation(s)
- Jung Woo Rhim
- Department of Pediatrics, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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12
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Izem R, McCarter R. Randomized and non-randomized designs for causal inference with longitudinal data in rare disorders. Orphanet J Rare Dis 2021; 16:491. [PMID: 34814939 PMCID: PMC8609847 DOI: 10.1186/s13023-021-02124-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
In the United States, approximately 7000 rare diseases affect 30 million patients, and only 10% of these diseases have existing therapies. Sound study design and causal inference methods are essential to demonstrate the therapeutic efficacy, safety, and effectiveness of new therapies. In the rare diseases setting, several factors challenge the use of typical parallel control designs: the small patient population size, genotypic and phenotypic diversity, and the complexity and incomplete understanding of the disorder’s progression. Repeated measures, when spaced appropriately relative to disease progression and exploited in design and analysis, can increase study power and reduce variability in treatment effect estimation. This paper reviews these longitudinal designs and draws the parallel between some new and existing randomized studies in rare diseases and their less well-known controlled observational study designs. We show that self-controlled randomized crossover and N-of-1 designs have similar considerations as the observational case series and case-crossover designs. Also, randomized sequential designs have similar considerations to longitudinal cohort studies using sequential matching or weighting to control confounding. We discuss design and analysis considerations for valid causal inference and illustrate them with examples of analyses in multiple rare disorders, including urea cycle disorder and cystic fibrosis.
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Affiliation(s)
- Rima Izem
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Medical Center, The George Washington University, Washington, DC, USA.
| | - Robert McCarter
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Medical Center, The George Washington University, Washington, DC, USA
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13
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Glaubitz S, Zeng R, Rakocevic G, Schmidt J. Update on Myositis Therapy: from Today's Standards to Tomorrow's Possibilities. Curr Pharm Des 2021; 28:863-880. [PMID: 34781868 DOI: 10.2174/1381612827666211115165353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/18/2021] [Indexed: 11/22/2022]
Abstract
Inflammatory myopathies, in short, myositis, are heterogeneous disorders that are characterized by inflammation of skeletal muscle and weakness of arms and legs. Research over the past few years has led to a new understanding regarding the pathogenesis of myositis. The new insights include different pathways of the innate and adaptive immune response during the pathogenesis of myositis. The importance of non-inflammatory mechanisms such as cell stress and impaired autophagy has been recently described. New target-specific drugs for myositis have been developed and are currently being tested in clinical trials. In this review, we discuss the mechanisms of action of pharmacological standards in myositis and provide an outlook of future treatment approaches.
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Affiliation(s)
- Stefanie Glaubitz
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen. Germany
| | - Rachel Zeng
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen. Germany
| | - Goran Rakocevic
- Department of Neurology, Neuromuscular Division, University of Virginia, Charlottesville. United States
| | - Jens Schmidt
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen. Germany
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14
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Varnier GC, Consolaro A, Maillard S, Pilkington C, Ravelli A. Comparison of treatments and outcomes of children with juvenile dermatomyositis followed at two European tertiary care referral centers. Rheumatology (Oxford) 2021; 60:5419-5423. [PMID: 33528490 DOI: 10.1093/rheumatology/keab089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/11/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To compare the treatment approaches and disease outcomes of children with JDM followed in two European tertiary care peadiatric rheumatology centres. METHODS The medical notes of patients with JDM seen at Istituto Giannina Gaslini (IGG) of Genoa, Italy or Great Ormond Street Hospital (GOSH) of London, UK between January 2000 and December 2015 within 6 months after disease onset and followed for at least 6 months were reviewed. Demographic, clinical and therapeutic data were collected. At each visit, the caring physician was asked to rate the disease state subjectively. RESULTS A total of 127 patients were included, 88 at GOSH and 39 at IGG. At 24 months, the median values of muscle strength and disease activity were at the normal end of the scale and around three quarters of patients were said to have inactive disease. Also, at 2 years, 38.6% and 36% of British and Italian patients, respectively, had damage. Cyclophosphamide, azathioprine, infliximab, rituximab and mycophenolate mofetil were used more frequently by UK physicians, whereas ciclosporin, intravenous immunoglobulin and hydroxychloroquine were prescribed by Italian physicians. CONCLUSION This study shows a significant difference in the choice of medications between pediatric rheumatologists practising in the two centres. Despite this, a high proportion of patients had inactive disease at 2 years and there was a low frequency of damage: modern treatments have improved outcomes.
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Affiliation(s)
- Giulia Camilla Varnier
- Dipartimento di Neuroscienze Riabilitazione Oftalmologia Genetica e Scienze MaternoInfantili, Università degli Studi di Genova, Genoa, Italy.,Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Alessandro Consolaro
- Dipartimento di Neuroscienze Riabilitazione Oftalmologia Genetica e Scienze MaternoInfantili, Università degli Studi di Genova, Genoa, Italy.,Dipartimento Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Susan Maillard
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Angelo Ravelli
- Dipartimento di Neuroscienze Riabilitazione Oftalmologia Genetica e Scienze MaternoInfantili, Università degli Studi di Genova, Genoa, Italy.,Dipartimento Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Paediatrics, Sechenov First Moscow State Medical University, Moscow, Russian Federation
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15
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Kim H, Huber AM, Kim S. Updates on Juvenile Dermatomyositis from the Last Decade: Classification to Outcomes. Rheum Dis Clin North Am 2021; 47:669-690. [PMID: 34635298 DOI: 10.1016/j.rdc.2021.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Juvenile dermatomyositis (JDM) is a heterogeneous disease with new classification criteria and updates in myositis-specific autoantibody and myositis-associated antibody groups. There are many validated assessment tools for assessing disease activity in JDM. Future studies will optimize these tools and improve feasibility in clinical and research contexts. Genetic and environmental risk factors, mechanisms of muscle pathology, role of interferon, vascular markers, and changes in immune cells provide insights to JDM pathogenesis. Outcomes have improved, but chronic disease, damage, and mortality highlight the need for better outcome predictors and treatments. Increased collaboration of stakeholders may help overcome research barriers and improve JDM treatment.
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Affiliation(s)
- Hanna Kim
- Juvenile Myositis Pathogenesis and Therapeutics Unit, National Institute of Arthritis Musculoskeletal and Skin Diseases, National Institutes of Health, 10 Center Drive, Building 10, 12N-240, Bethesda, MD 20892, USA.
| | - Adam M Huber
- IWK Health Centre and Dalhousie University, Division of Pediatric Rheumatology, 5850 University Avenue, Halifax, Nova Scotia B3K 6R8, Canada
| | - Susan Kim
- University of California, San Francisco, 550 16th Street, San Francisco, CA 94158, USA
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16
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Ll Wilkinson MG, Deakin CT, Papadopoulou C, Eleftheriou D, Wedderburn LR. JAK inhibitors: a potential treatment for JDM in the context of the role of interferon-driven pathology. Pediatr Rheumatol Online J 2021; 19:146. [PMID: 34563217 PMCID: PMC8466894 DOI: 10.1186/s12969-021-00637-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/28/2021] [Indexed: 12/29/2022] Open
Abstract
Juvenile Idiopathic Inflammatory Myopathies (IIM) are a group of rare diseases that are heterogeneous in terms of pathology that can include proximal muscle weakness, associated skin changes and systemic involvement. Despite options for treatment, many patients continue to suffer resistant disease and lasting side-effects. Advances in the understanding of the immunopathology and genetics underlying IIM may specify new therapeutic targets, particularly where conventional treatment has not achieved a clinical response. An upregulated type I interferon signature is strongly associated with disease and could be a prime target for developing more specific therapeutics. There are multiple components of the IFN pathway that could be targeted for blockade therapy.Downstream of the cytokine receptor complexes are the Janus kinase-signal transducers and activators of transcription (JAK-STAT) pathway, which consists of JAK1-3, TYK2, and STAT1-6. Therapeutic inhibitors have been developed to target components of this pathway. Promising results have been observed in case studies reporting the use of the JAK inhibitors, Baricitinib, Tofacitinib and Ruxolitinib in the treatment of refractory Juvenile Dermatomyositis (JDM). There is still the question of safety and efficacy for the use of JAK inhibitors in JDM that need to be addressed by clinical trials. Here we review the future for the use of JAK inhibitors as a treatment for JDM.
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Affiliation(s)
- Meredyth G Ll Wilkinson
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, University College London, London, UK.
- NIHR Biomedical Research Centre at GOSH, London, UK.
| | - Claire T Deakin
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, University College London, London, UK
- NIHR Biomedical Research Centre at GOSH, London, UK
| | - Charalampia Papadopoulou
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
- Rheumatology, Great Ormond Street Hospital, Great Ormond Street, London, UK
| | - Despina Eleftheriou
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
- Rheumatology, Great Ormond Street Hospital, Great Ormond Street, London, UK
| | - Lucy R Wedderburn
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, University College London, London, UK
- NIHR Biomedical Research Centre at GOSH, London, UK
- Rheumatology, Great Ormond Street Hospital, Great Ormond Street, London, UK
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17
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Deakin CT, Papadopoulou C, McCann LJ, Martin N, Al-Obaidi M, Compeyrot-Lacassagne S, Pilkington CA, Tansley SL, McHugh NJ, Wedderburn LR, De Stavola BL. Identification and prediction of novel classes of long-term disease trajectories for patients with juvenile dermatomyositis using growth mixture models. Rheumatology (Oxford) 2021; 60:1891-1901. [PMID: 33146389 PMCID: PMC8023987 DOI: 10.1093/rheumatology/keaa497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/11/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives Uncertainty around clinical heterogeneity and outcomes for patients with JDM represents a major burden of disease and a challenge for clinical management. We sought to identify novel classes of patients having similar temporal patterns in disease activity and relate them to baseline clinical features. Methods Data were obtained for n = 519 patients, including baseline demographic and clinical features, baseline and follow-up records of physician’s global assessment of disease (PGA), and skin disease activity (modified DAS). Growth mixture models (GMMs) were fitted to identify classes of patients with similar trajectories of these variables. Baseline predictors of class membership were identified using Lasso regression. Results GMM analysis of PGA identified two classes of patients. Patients in class 1 (89%) tended to improve, while patients in class 2 (11%) had more persistent disease. Lasso regression identified abnormal respiration, lipodystrophy and time since diagnosis as baseline predictors of class 2 membership, with estimated odds ratios, controlling for the other two variables, of 1.91 for presence of abnormal respiration, 1.92 for lipodystrophy and 1.32 for time since diagnosis. GMM analysis of modified DAS identified three classes of patients. Patients in classes 1 (16%) and 2 (12%) had higher levels of modified DAS at diagnosis that improved or remained high, respectively. Patients in class 3 (72%) began with lower DAS levels that improved more quickly. Higher proportions of patients in PGA class 2 were in DAS class 2 (19%, compared with 16 and 10%). Conclusion GMM analysis identified novel JDM phenotypes based on longitudinal PGA and modified DAS.
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Affiliation(s)
- Claire T Deakin
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, UK.,Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCL Hospitals and Great Ormond Street Hospital, London, UK.,NIHR Biomedical Research Centre at Great Ormond Street Hospital, London, UK
| | - Charalampia Papadopoulou
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, UK.,Rheumatology Unit, Great Ormond Street Hospital, London, UK
| | - Liza J McCann
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Neil Martin
- Rheumatology Department, Royal Hospital for Sick Children, Glasgow
| | | | | | | | - Sarah L Tansley
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Neil J McHugh
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Lucy R Wedderburn
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, UK.,Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCL Hospitals and Great Ormond Street Hospital, London, UK.,NIHR Biomedical Research Centre at Great Ormond Street Hospital, London, UK.,Rheumatology Unit, Great Ormond Street Hospital, London, UK
| | - Bianca L De Stavola
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
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18
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Doudouliaki T, Papadopoulou C, Deakin CT. Use of Rescue Therapy with IVIG or Cyclophosphamide in Juvenile Myositis. Curr Rheumatol Rep 2021; 23:24. [PMID: 33686540 DOI: 10.1007/s11926-021-00990-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to present the literature available to date on the use of intravenous immunoglobulin and cyclophosphamide for juvenile patients with inflammatory myopathies, to evaluate the strength of the evidence so far for both these medications, and to reach conclusions about their efficacy. RECENT FINDINGS Juvenile idiopathic inflammatory myopathies, mainly represented by juvenile dermatomyositis (JDM), are rare diseases but quite debilitating for the patients. JDM is an autoimmune condition with predominantly muscle and skin involvement but also systemic features affecting the cardiovascular, respiratory, and gastrointestinal systems. The mainstay therapy is based on corticosteroids and methotrexate, but often other therapeutic alternatives are sought for patients with severe or refractory disease. The rarity of these conditions makes research for new medications even more challenging. Innovative trial designs or statistical methods can be used to emulate a randomized study and investigate drug effectiveness. Despite the lack of Level I evidence on the use and efficacy of intravenous immunoglobulin and cyclophosphamide, their use is advocated by a substantial number of case reports and case series as well as analyses using marginal structural models.
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Affiliation(s)
- Theonymfi Doudouliaki
- Department of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Charalampia Papadopoulou
- Department of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Research and Teaching Department, UCL, Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Claire T Deakin
- Infection, Immunity and Inflammation Research and Teaching Department, UCL, Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
- Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London, UK.
- NIHR Biomedical Research Centre at Great Ormond Street Hospital, London, UK.
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19
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Pachman LM, Nolan BE, DeRanieri D, Khojah AM. Juvenile Dermatomyositis: New Clues to Diagnosis and Therapy. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021; 7:39-62. [PMID: 34354904 PMCID: PMC8336914 DOI: 10.1007/s40674-020-00168-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To identify clues to disease activity and discuss therapy options. RECENT FINDINGS The diagnostic evaluation includes documenting symmetrical proximal muscle damage by exam and MRI, as well as elevated muscle enzymes-aldolase, creatine phosphokinase, LDH, and SGOT-which often normalize with a longer duration of untreated disease. Ultrasound identifies persistent, occult muscle inflammation. The myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) are associated with specific disease course variations. Anti-NXP-2 is found in younger children and is associated with calcinosis; anti-TIF-1γ+ juvenile dermatomyositis has a longer disease course. The diagnostic rash-involving the eyelids, hands, knees, face, and upper chest-is the most persistent symptom and is associated with microvascular compromise, reflected by loss of nailfold (periungual) end row capillaries. This loss is associated with decreased bioavailability of oral prednisone; the bioavailability of other orally administered medications should also be considered. At diagnosis, at least 3 days of intravenous methyl prednisolone may help control the HLA-restricted and type 1/2 interferon-driven inflammatory process. The requirement for avoidance of ultraviolet light exposure mandates vitamin D supplementation. SUMMARY This often chronic illness targets the cardiovascular system; mortality has decreased from 30 to 1-2% with corticosteroids. New serological biomarkers indicate occult inflammation: ↑CXCL-10 predicts a longer disease course. Some biologic therapies appear promising.
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Affiliation(s)
- Lauren M. Pachman
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Cure JM Center of Excellence in Juvenile Myositis Research and Care, The Stanley Manne Research Center for Children, Chicago, IL, USA
| | - Brian E. Nolan
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Deidre DeRanieri
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Amer M. Khojah
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Division of Allergy/Immunology, Chicago, IL, USA, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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20
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Kul Cinar O, Papadopoulou C, Pilkington CA. Treatment of Calcinosis in Juvenile Dermatomyositis. Curr Rheumatol Rep 2021; 23:13. [PMID: 33555459 DOI: 10.1007/s11926-020-00974-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Juvenile dermatomyositis (JDM) is a rare autoimmune disease characterised by muscle and skin involvement. Calcinosis is a debilitating complication of JDM which is difficult to treat and may cause long-term morbidity. The purpose of this review is to provide an update for the treatment of JDM-associated calcinosis based on previously published studies. RECENT FINDINGS Evidence-based studies are lacking for the management of calcinosis, and current treatment modalities have been largely based on case reports, case series, cohort studies, limited controlled studies and anecdotal clinical experience. The use of early aggressive therapy for resistant cases is strongly suggested to halt persistent disease activity which may help in reducing steroid use and their associated complications. Recent insights into disease pathogenesis, myositis-specific antibodies and genetic associations have led to identification of novel therapeutic targets such as Janus kinase (JAK) 1/2. Different treatment regimens with variable outcomes are in use for the treatment of refractory calcinosis; nevertheless, the level of evidence is not sufficient to propose specific guidelines. Recently, JAK 1/2 inhibitors have shown to be effective as an emerging therapeutic option highlighting that translational and clinical research is crucial to develop targeted treatment for JDM-associated calcinosis.
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Affiliation(s)
- Ovgu Kul Cinar
- Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK. .,Division of Infection and Immunity, University College London, London, WC1E 6BT, UK.
| | - Charalampia Papadopoulou
- Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,Infection, Inflammation and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Clarissa A Pilkington
- Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,NIHR Biomedical Research Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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21
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Leung AKC, Lam JM, Alobaida S, Leong KF, Wong AHC. Juvenile Dermatomyositis: Advances in Pathogenesis, Assessment, and Management. Curr Pediatr Rev 2021; 17:273-287. [PMID: 33902423 DOI: 10.2174/1573396317666210426105045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Juvenile dermatomyositis is the most common inflammatory myopathy in the pediatric age group and a major cause of mortality and morbidity in individuals with childhood rheumatic diseases. Mounting evidence suggests that early diagnosis and timely aggressive treatment are associated with better outcomes. OBJECTIVE The purpose of this article is to provide readers with an update on the evaluation, diagnosis, and the treatment of juvenile dermatomyositis. METHODS A PubMed search was performed in Clinical Queries using the key term "juvenile dermatomyositis" in the search engine. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. The information retrieved from the above search was used in the compilation of the present article. RESULTS Juvenile dermatomyositis is a chronic autoimmune inflammatory condition characterized by systemic capillary vasculopathy that primarily affects the skin and muscles with possible involvement of other organs. In 2017, the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) developed diagnostic criteria for juvenile idiopathic inflammatory myopathies and juvenile dermatomyositis. In the absence of muscle biopsies which are infrequently performed in children, scores (in brackets) are assigned to four variables related to muscle weakness, three variables related to skin manifestations, one variable related to other clinical manifestations, and two variables related to laboratory measurements to discriminate idiopathic inflammatory myopathies from non-idiopathic inflammatory myopathies as follows: objective symmetric weakness, usually progressive, of the proximal upper extremities (0.7); objective symmetric weakness, usually progressive, of the proximal lower extremities (0.8); neck flexors relatively weaker than neck extensors (1.9); leg proximal muscles relatively weaker than distal muscles (0.9); heliotrope rash (3.1); Gottron papules (2.1); Gottron sign (3.3); dysphagia or esophageal dysmotility (0.7); the presence of anti-Jo-1 autoantibody (3.9); and elevated serum levels of muscle enzymes (1.3). In the absence of muscle biopsy, a definite diagnosis of idiopathic inflammatory myopathy can be made if the total score is ≥7.5. Patients whose age at onset of symptoms is less than 18 years and who meet the above criteria for idiopathic inflammatory myopathy and have a heliotrope rash, Gottron papules or Gottron sign are deemed to have juvenile dermatomyositis. The mainstay of therapy at the time of diagnosis is a high-dose corticosteroid (oral or intravenous) in combination with methotrexate. CONCLUSION For mild to moderate active muscle disease, early aggressive treatment with high-dose oral prednisone alone or in combination with methotrexate is the cornerstone of management. Pulse intravenous methylprednisolone is often preferred to oral prednisone in more severely affected patients, patients who respond poorly to oral prednisone, and those with gastrointestinal vasculopathy. Other steroid-sparing immunosuppressive agents such as cyclosporine and cyclophosphamide are reserved for patients with contraindications or intolerance to methotrexate and for refractory cases, as the use of these agents is associated with more adverse events. Various biological agents have been used in the treatment of juvenile dermatomyositis. Data on their efficacy are limited, and their use in the treatment of juvenile dermatomyositis is considered investigational.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta,Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, The University of British Columbia, Vancouver, British Columbia,Canada
| | - Saud Alobaida
- Department of Dermatology, King Faisal Specialist Hospital & Research Centre, Riyadh,Saudi Arabia
| | - Kin F Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur,Malaysia
| | - Alex H C Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta,Canada
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22
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Campanilho-Marques R, Deakin CT, Simou S, Papadopoulou C, Wedderburn LR, Pilkington CA. Retrospective analysis of infliximab and adalimumab treatment in a large cohort of juvenile dermatomyositis patients. Arthritis Res Ther 2020; 22:79. [PMID: 32293539 PMCID: PMC7161150 DOI: 10.1186/s13075-020-02164-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 03/27/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anti-TNF treatment may be useful for the treatment of patients with refractory juvenile dermatomyositis (JDM). The aim of this study was to describe the use of infliximab and adalimumab therapy in juvenile dermatomyositis as an adjunctive treatment. METHODS Sixty children recruited to the UK JDM Cohort and Biomarker Study that had received at least 3 months of anti-TNF treatment (infliximab or adalimumab) were studied. Childhood Myositis Assessment Scale (CMAS), Manual Muscle Testing (MMT8) and physician's global assessment (PGA) were recorded. Skin disease was assessed using the modified skin disease activity score (DAS). Data were analysed using Friedman's test for repeated measures analysis of variance. RESULTS Compared to baseline, there were improvements at 6 and 12 months in skin disease (χ2(2) = 15.52, p = 0.00043), global disease (χ2(2) = 8.14, p = 0.017) and muscle disease (CMAS χ2(2) = 17.02, p = 0.0002 and MMT χ2(2) = 10.56, p = 0.005) in infliximab patients. For patients who switched from infliximab to adalimumab, there was improvement in global disease activity (χ2(2) = 6.73, p = 0.03), and trends towards improvement in CMAS, MMT8 and modified DAS. The median initial prednisolone dose was 6 [0-10] mg, and final was 2.5 [0-7.5] mg (p < 0.0001). Fifty-four per cent of patients had a reduction in the number and/or size of calcinosis lesions. Twenty-five per cent switched their anti-TNF treatment from infliximab to adalimumab. 66.7%of the switches were to improve disease control, 26.7% due to adverse events and 6.6% due to patient preference. A total of 13.9 adverse reactions occurred in 100 patient-years, of which 5.7 were considered serious. CONCLUSION Reductions in muscle and skin disease, including calcinosis, were seen following treatment with infliximab and adalimumab.
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Affiliation(s)
- Raquel Campanilho-Marques
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute for Child Health, London, UK
- Rheumatology Section, Great Ormond Street Hospital for Children NHS Trust, Level 6 Southwood Building, Great Ormond Street, London, WC1N 3JH, UK
- NIHR Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, CHULN-Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa-Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Claire T Deakin
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute for Child Health, London, UK
- NIHR Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London, UK
| | - Stefania Simou
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute for Child Health, London, UK
| | - Charalampia Papadopoulou
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute for Child Health, London, UK
- Rheumatology Section, Great Ormond Street Hospital for Children NHS Trust, Level 6 Southwood Building, Great Ormond Street, London, WC1N 3JH, UK
| | - Lucy R Wedderburn
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute for Child Health, London, UK
- Rheumatology Section, Great Ormond Street Hospital for Children NHS Trust, Level 6 Southwood Building, Great Ormond Street, London, WC1N 3JH, UK
- NIHR Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London, UK
| | - Clarissa A Pilkington
- Rheumatology Section, Great Ormond Street Hospital for Children NHS Trust, Level 6 Southwood Building, Great Ormond Street, London, WC1N 3JH, UK.
- NIHR Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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23
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Kobayashi I, Akioka S, Kobayashi N, Iwata N, Takezaki S, Nakaseko H, Sato S, Nishida Y, Nozawa T, Yamasaki Y, Yamazaki K, Arai S, Nishino I, Mori M. Clinical practice guidance for juvenile dermatomyositis (JDM) 2018-Update. Mod Rheumatol 2020; 30:411-423. [PMID: 31955618 DOI: 10.1080/14397595.2020.1718866] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Juvenile dermatomyositis is the most common type of juvenile idiopathic inflammatory myopathy mainly affecting the skin and proximal muscles. We have published the Japanese version of 'Clinical practice guidance for juvenile dermatomyositis (JDM) 2018 'consisting of a review of articles in the field and evidence-informed consensus-based experts' opinion on the treatment strategy in collaboration with The Pediatric Rheumatology Association of Japan and The Japan College of Rheumatology under the financial support by 'Research on rare and intractable diseases, Health and Labor Sciences Research Grants'. This article is a digest version of the Japanese guidance.
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Affiliation(s)
- Ichiro Kobayashi
- Center for Pediatric Allergy and Rheumatology, KKR Sapporo Medical Center, Sapporo, Japan
| | - Shinji Akioka
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Norimoto Kobayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | | | - Haruna Nakaseko
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | - Satoshi Sato
- Division of Infectious Disease and Immunology, Saitama Children's Medical Center, Omiya, Japan
| | - Yutaka Nishida
- Department of Pediatrics, School of Medicine, Gunma University, Maebashi, Japan
| | - Tomo Nozawa
- Department of Pediatrics, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yuichi Yamasaki
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Kazuko Yamazaki
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Satoru Arai
- Department of Dermatology, St. Luke's International Hospital, Tokyo, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masaaki Mori
- Lifetime Clinical Immunology, Tokyo Medical and Dental University, Tokyo, Japan
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24
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Wu JQ, Lu MP, Reed AM. Juvenile dermatomyositis: advances in clinical presentation, myositis-specific antibodies and treatment. World J Pediatr 2020; 16:31-43. [PMID: 31556011 DOI: 10.1007/s12519-019-00313-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is a chronic autoimmune disease characteristic by inflammation of small vessels within the skin, muscle and vital organs. But the clinical features and treatment of JDM have not been fully clarified. DATA SOURCES Databases underwent through PubMed for articles about the clinical features, myositis-specific antibodies of JDM and its treatment, and we selected publications written in English which were relevant to the topic of this review. RESULTS Clinical features and myositis-specific antibodies may predict the severity and prognosis of disease. Although the mortality rate has been lower with traditional treatments, such as corticosteroid, intravenous immunoglobulin, and disease-modifying anti-rheumatic drugs such as methotrexate, their usages are variable. Novel biological therapies seem to be effective for refractory JDM patients, but more clinical trials are necessary. CONCLUSIONS JDM is a sever disease of childhood. We need to better understand recent advances of JDM in the context of clinical features including skin manifestations, muscle weakness and organ damage, myositis-specific antibodies and their associated outcomes and the treatment of disease.
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Affiliation(s)
- Jian-Qiang Wu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Mei-Ping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Ann M Reed
- Department of Pediatrics, Division of Pediatric Rheumatology, Duke University School of Medicine, Durham, 27710, USA.
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25
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Glaubitz S, Zeng R, Schmidt J. New insights into the treatment of myositis. Ther Adv Musculoskelet Dis 2020; 12:1759720X19886494. [PMID: 31949477 PMCID: PMC6950531 DOI: 10.1177/1759720x19886494] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/10/2019] [Indexed: 12/17/2022] Open
Abstract
The myositis syndromes include polymyositis, dermatomyositis (DM), necrotizing myopathy, inclusion body myositis (IBM), antisynthetase syndrome and overlap syndromes with myositis. These syndromes mostly occur in middle-aged patients, while juvenile DM occurs in children and adolescents. Patients mostly show a subacute weakness and myalgia in the upper and lower limbs, the diagnosis is based upon these clinical findings in combination with muscle biopsy results and specific serum autoantibodies. In recent years, research achieved a better understanding about the molecular mechanism underlying the myositis syndromes, as well as disease progress and extramuscular organ manifestations, such as interstitial lung disease and association with neoplasias. Treatment mainly consists of glucocorticosteroids and immunosuppressants. IBM is usually refractory to treatments. This review provides an overview of the current standards of treatment and new treatment options like monoclonal antibodies and new molecular therapies and their first results from clinical trials.
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Affiliation(s)
- Stefanie Glaubitz
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Rachel Zeng
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Robert-Koch-Sr. 40, 37075 Göttingen, Germany
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26
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Juvenile dermatomyositis resembling late-stage Degos disease with gastrointestinal perforations successfully treated with combination of cyclophosphamide and rituximab: case-based review. Rheumatol Int 2020; 40:1883-1890. [PMID: 31900501 DOI: 10.1007/s00296-019-04495-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
Dermatomyositis (DM) is a multi-system disease that results in chronic inflammation principally of the skin and striated muscle. Small blood vessel injury in the GI tract has been described in dermatomyositis, manifesting as bleeding, ulceration, pneumatosis intestinalis, and ultimately perforation. Recent histopathological studies have shown deposits in the capillaries of the skin, gastrointestinal tract, and brain of patients with dermatomyositis similar to that found in patients with Degos disease, suggesting these disease processes are closely related or represent varying degrees of severity on the same pathologic spectrum. We report a case of juvenile dermatomyositis (JDM) resembling late-stage Degos disease with gastrointestinal perforations successfully treated with combination rituximab and cyclophosphamide therapy. We systematically reviewed the literature detailing the medical and surgical treatments for gastrointestinal perforation in dermatomyositis, Degos-like dermatomyositis, and Degos disease. In addition to our case, as of October 2019, we identified 36 cases describing gastrointestinal perforation in patients with underlying dermatomyositis, 5 cases of Degos-like dermatomyositis and 17 cases of idiopathic Degos disease. Corticosteroid therapy was used widely for dermatomyositis and Degos-like dermatomyositis, while antiplatelet and anticoagulant medications were chiefly used for patients with idiopathic Degos disease. However, there were no cases that detailed the successful treatment of dermatomyositis or Degos disease with gastrointestinal perforation with rituximab alone or combined with cyclophosphamide. We report that rituximab, in combination with cyclophosphamide, can be used as a novel adjunctive therapy to successfully treat dermatomyositis with Degos-like gastrointestinal perforation.
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27
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Vezzola D, Allegrini D, Romano MR, Pagano L, Montericcio A, Fogagnolo P, Rossetti LM, De Cillà S. Optical coherence tomography angiography in Purtscher-like retinopathy associated with dermatomyositis: a case report. J Med Case Rep 2019; 13:206. [PMID: 31277711 PMCID: PMC6612075 DOI: 10.1186/s13256-019-2152-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 06/10/2019] [Indexed: 01/19/2023] Open
Abstract
Purpose To describe a multimodal imaging diagnosis of retinopathy in dermatomyositis. Case presentation A 21-year-old white woman with a history of fatigue and a cutaneous rash complained of visual impairment in her left eye. A funduscopic examination showed multiple confluent cotton-wool spots in both eyes. Swept source-optical coherence tomography presented macular edema in both eyes; optical coherence tomography angiography revealed superficial and deep capillary occlusion in all areas affected by cotton-wool spots; and fluorescein angiography showed vascular walls enhancement, veins dilatation, and capillary leakage. After large doses of intravenously administered glucocorticoid therapy, followed by a cyclophosphamide regimen, best corrected visual acuity returned to 20/20 in both eyes. Conclusions This case report presents optical coherence tomography angiography clinical findings in a rare case of dermatomyositis-associated retinopathy, remarking the importance of a multi-imaging approach for a correct diagnosis and treatment of eye injuries, in order to avoid serious complications and permanent sequelae.
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Affiliation(s)
- D Vezzola
- Eye Unit, University Hospital Maggiore della Carita, Novara, Italy.,Eye Clinic, Humanitas Castelli, Humanitas Gavazzeni Hospital, Humanitas University, Bergamo, Italy
| | - D Allegrini
- Eye Clinic, Humanitas Castelli, Humanitas Gavazzeni Hospital, Humanitas University, Bergamo, Italy.
| | - M R Romano
- Eye Clinic, Humanitas Castelli, Humanitas Gavazzeni Hospital, Humanitas University, Bergamo, Italy
| | - L Pagano
- Eye Clinic, Humanitas Castelli, Humanitas Gavazzeni Hospital, Humanitas University, Bergamo, Italy
| | - A Montericcio
- Eye Clinic, Humanitas Castelli, Humanitas Gavazzeni Hospital, Humanitas University, Bergamo, Italy
| | - P Fogagnolo
- Eye Clinic, San Paolo Hospital, University of Milan, Milan, Italy
| | - L M Rossetti
- Eye Clinic, San Paolo Hospital, University of Milan, Milan, Italy
| | - S De Cillà
- Eye Unit, University Hospital Maggiore della Carita, Novara, Italy
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28
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Waldman R, DeWane ME, Lu J. Dermatomyositis: Diagnosis and treatment. J Am Acad Dermatol 2019; 82:283-296. [PMID: 31279813 DOI: 10.1016/j.jaad.2019.05.105] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/09/2019] [Accepted: 05/11/2019] [Indexed: 12/13/2022]
Abstract
The second article in this continuing medical education series reviews the initial evaluation of patients with suspected dermatomyositis (DM), the relevant work-up for malignancy and interstitial lung disease once a diagnosis of DM is made, and treatment recommendations for patients with DM based on disease severity, the presence of systemic symptoms, and myositis-specific antibody (MSA) profiles. This review emphasizes the emerging role of MSAs in the diagnosis of DM and highlights how MSAs can be used to guide the appropriate work-up for malignancy and interstitial lung disease. The treatment approach proposed by this continuing medical education series discusses both established and novel therapies for DM and highlights the importance of considering lesion type, degree of muscle involvement, presence of systemic symptoms, presence of MSAs, and patient age when determining the best treatment approach for a patient with DM.
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Affiliation(s)
- Reid Waldman
- Department of Dermatology, University of Connecticut, Farmington, Connecticut
| | - Madeline E DeWane
- University of Connecticut, School of Medicine, Farmington, Connecticut
| | - Jun Lu
- Department of Dermatology, University of Connecticut, Farmington, Connecticut.
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29
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Wakiguchi H. Multispecialty approach for improving outcomes in juvenile dermatomyositis. J Multidiscip Healthc 2019; 12:387-394. [PMID: 31213823 PMCID: PMC6549682 DOI: 10.2147/jmdh.s171095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/11/2019] [Indexed: 11/23/2022] Open
Abstract
Juvenile dermatomyositis (JDM) is a pediatric rheumatic disease characterized by inflammation of the muscle and skin. Prognosis of JDM in children has improved in general owing to medical progress; however, pathogenesis and management of JDM in children and prognosis in refractory JDM remain challenging. For elucidation of JDM pathophysiology and establishment of appropriate treatment for JDM, pediatric rheumatologists need to adopt a multispecialty approach that involves experts in genetics, immunology, pathology, musculoskeletal medicine, dermatology, pulmonology, cardiology, hematology, gastroenterology, endocrinology, ophthalmology, psychology, radiology, pharmacology, physiotherapy, surgery, preventive medicine, and adult rheumatology. Such collaborations will potentially lead to improved outcomes in children with JDM.
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Affiliation(s)
- Hiroyuki Wakiguchi
- Department of Pediatrics, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
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30
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Livermore P, Gray S, Mulligan K, Stinson JN, Wedderburn LR, Gibson F. Being on the juvenile dermatomyositis rollercoaster: a qualitative study. Pediatr Rheumatol Online J 2019; 17:30. [PMID: 31215480 PMCID: PMC6582587 DOI: 10.1186/s12969-019-0332-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/22/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Juvenile Dermatomyositis is a rare, potentially life-threatening condition with no known cure. There is no published literature capturing how children and young people feel about their condition, from their perspective. This study was therefore unique in that it asked children and young people what is it like to live with Juvenile Dermatomyositis. METHODS Data were obtained from fifteen young people with Juvenile Dermatomyositis, between eight and nineteen years of age from one Paediatric Rheumatology department using audio-recorded interpretive phenomenology interviews. Data were analyzed phenomenologically, using a process that derives narratives from transcripts resulting in a collective composite of participants shared experiences, called a 'phenomenon'. RESULTS The overarching metaphor of a rollercoaster captures the phenomenon of living with Juvenile Dermatomyositis as a young person, with the ups and downs at different time points clearly described by those interviewed. The five themes plotted on the rollercoaster, began with confusion; followed by feeling different, being sick, steroidal and scared from the medications; uncertainty; and then ended with acceptance of the disease over time. CONCLUSION Young people were able to talk about their experiences about having Juvenile Dermatomyositis. Our findings will aid clinicians in their practice by gaining a deeper understanding of what daily life is like and highlighting ways to enhance psychosocial functioning. Hopefully, this study and any further resulting studies, will raise understanding of Juvenile Dermatomyositis worldwide and will encourage health care professionals to better assess psychosocial needs in the future.
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Affiliation(s)
- Polly Livermore
- University College London Great Ormond Street Institute of Child Health, London, UK. .,Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK. .,Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, London, UK. .,NIHR Clinical Doctoral Research Nursing Fellow, Infection, Immunity and Inflammation, 6th Floor, Institute of Child Health, University College London Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Suzanne Gray
- 0000 0004 5345 7223grid.483570.dEvelina London Children’s Hospital, GSTT NHS Foundation Trust, London, UK
| | - Kathleen Mulligan
- 0000 0004 1936 8497grid.28577.3fCity, University of London, London, UK ,0000 0004 0426 7183grid.450709.fEast London NHS Foundation Trust, London, UK
| | - Jennifer N. Stinson
- 0000 0004 0473 9646grid.42327.30Hospital for Sick Children, Toronto, Canada ,0000 0001 2157 2938grid.17063.33Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Lucy R. Wedderburn
- 0000000121901201grid.83440.3bUniversity College London Great Ormond Street Institute of Child Health, London, UK ,0000 0001 2116 3923grid.451056.3NIHR Biomedical Research Centre at Great Ormond Street Hospital, London, UK ,0000000121901201grid.83440.3bCentre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, London, UK
| | - Faith Gibson
- 0000 0004 5902 9895grid.424537.3Centre for Outcomes and Experience Research in Children’s Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK ,0000 0004 0407 4824grid.5475.3School of Health Sciences, University of Surrey, Surrey, UK
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31
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Reed AM, Crowson CS, Dvergsten JA. A Path to Prediction of Outcomes in Juvenile Idiopathic Inflammatory Myopathy. Front Immunol 2019; 10:638. [PMID: 31001260 PMCID: PMC6454149 DOI: 10.3389/fimmu.2019.00638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/08/2019] [Indexed: 12/20/2022] Open
Abstract
Humans have an innate desire to observe and subsequently dissect an event into component pieces in an effort to better characterize the event. We then examine these pieces individually and in combinations using this information to determine the outcome of future similar events and the likelihood of their recurrence. Practically, this attempt to foretell an occurrence and predict its outcomes is evident in multiple disciplines ranging from meteorology to sociologic studies. In this manuscript we share the historical and present-day tools to predict course and outcome in juvenile idiopathic inflammatory myopathy including clinical features, testing, and biomarkers. Further we discuss considerations for building more complex predictive models of outcome especially in diseases such as juvenile idiopathic inflammatory myopathy where patients numbers are low. Many of the barriers to developing risk prediction models for juvenile idiopathic inflammatory myopathy outcomes have improved with many remaining challenges being addressed.
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Affiliation(s)
- Ann Marie Reed
- School of Medicine, Duke University, Durham, NC, United States.,Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, Durham, NC, United States
| | | | - Jeffrey Arthur Dvergsten
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, Durham, NC, United States
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32
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Wilkinson MGL, Rosser EC. B Cells as a Therapeutic Target in Paediatric Rheumatic Disease. Front Immunol 2019; 10:214. [PMID: 30837988 PMCID: PMC6382733 DOI: 10.3389/fimmu.2019.00214] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022] Open
Abstract
B cells carry out a central role in the pathogenesis of autoimmune disease. In addition to the production of autoantibodies, B cells can contribute to disease development by presenting autoantigens to autoreactive T cells and by secreting pro-inflammatory cytokines and chemokines which leads to the amplification of the inflammatory response. Targeting both the antibody-dependent and antibody-independent function of B cells in adult rheumatic disease has led to the advent of B cell targeted therapies in clinical practice. To date, whether B cell depletion could also be utilized for the treatment of pediatric disease is relatively under explored. In this review, we will discuss the role of B cells in the pathogenesis of the pediatric rheumatic diseases Juvenile Idiopathic Arthritis (JIA), Juvenile Systemic Lupus Erythematosus (JSLE) and Juvenile Dermatomyositis (JDM). We will also explore the rationale behind the use of B cell-targeted therapies in pediatric rheumatic disease by highlighting new case studies that points to their efficacy in JIA, JSLE, and JDM.
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Affiliation(s)
- Meredyth G Ll Wilkinson
- Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, UCLH and GOSH, London, United Kingdom.,NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, United Kingdom
| | - Elizabeth C Rosser
- Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, UCLH and GOSH, London, United Kingdom.,NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, United Kingdom
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34
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Abstract
INTRODUCTION Juvenile dermatomyositis (JDM) is a rare, chronic autoimmune illness with primary features of symmetric, proximal muscle weakness and involvement of the skin with a number of identifiable rashes. Evidence to support treatment decisions is limited, given the paucity of clinical trials. Consensus based methods, informed by available data, play an important role in treatment recommendations. Areas covered: This review focuses on evidence and consensus opinion regarding therapeutic options in JDM and identifies gaps where future research is needed. Expert commentary: The combination of trial evidence (as limited as it is) and consensus opinion support standard initial management for children with JDM to consist of high-dose corticosteroids, either intravenous or oral, and methotrexate. Several other agents have preliminary support, either through clinical trials or case series for their use in patients who either fail to respond adequately, have severe disease or have contraindications to standard initial therapy. One of the important goals of management in JDM will be to reduce the corticosteroid exposure experienced by patients. To meet this goal, progress in a number of key areas is needed: increased international collaboration, advances in study design and increased translational research.
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Affiliation(s)
- Adam M Huber
- a Division of Pediatric Rheumatology , Dalhousie University , Halifax , Nova Scotia , Canada
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35
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Bae S, Charles-Schoeman C. Oral cyclophosphamide in treatment of patients with refractory idiopathic inflammatory myopathies: a retrospective observational study. Clin Rheumatol 2018; 37:2113-2123. [PMID: 29971584 DOI: 10.1007/s10067-018-4174-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/02/2018] [Accepted: 06/04/2018] [Indexed: 01/19/2023]
Abstract
To describe the use of oral cyclophosphamide (PO CYC) in a single center longitudinal cohort of patients with idiopathic inflammatory myopathies (IIM). Patients using PO CYC were identified through a retrospective chart review of a myositis cohort at a single academic center. PO CYC dose, duration, adverse events, and disease activity measures before and after CYC were analyzed. Disease activity measures included muscle enzymes, manual muscle testing (MMT8), 100-mm visual analog scale (VAS), and 1-4 Likert scale for physician global assessment. Fourteen patients were treated with PO CYC within the cohort between 2008 and 2017; 9 dermatomyositis (DM), 3 polymyositis (PM), and 2 with immune-mediated necrotizing myopathy (IMNM). Age was 51.1 (40-72) years and the cumulative dose of PO CYC was 41 (2-131) grams over duration of 12.4 (0.5-43) months, mean (range) for all. All patients had severe refractory IIM, 10 (72%) with ILD, 3 (21%) with cardiac involvement and 4 (29%) were dependent in most activities of daily living. Median number of prior failed therapies was 4.5 (range 3-6) including intravenous CYC in 5 patients. Disease activity measures significantly improved following CYC use and concomitant daily prednisone dose decreased. The most common adverse events during CYC therapy were infections. We report the first cohort study of PO CYC use in IIM patients with severe, treatment refractory disease. Further trials are needed to verify these results as well as to evaluate long-term safety outcomes.
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Affiliation(s)
- Sangmee Bae
- Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA.
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Abstract
Juvenile dermatomyositis (JDM) is a rare autoimmune disease mainly characterized by muscle and skin involvement. Vasculopathy is considered central to the pathogenesis of the disease. The exact nature of vasculopathy is not yet understood but it is a complex process with both an inflammatory and a non-inflammatory, occlusive component. Impaired function of JDM vasculature includes immune complex deposition, altered expression of cell adhesion molecules predominantly inducing Th17 cell infiltration, and endothelial cell dysfunction. Development of vasculopathy is associated with the severe extra-muscular manifestations of JDM, such as gastrointestinal and cardiac manifestations, interstitial lung disease, ulcerative skin disease or development of calcinosis, and portends a poor prognosis. Correlation of histopathological findings, autoantibodies, and extensive diagnostic workup represent key elements to the early detection of vasculopathic features and early aggressive treatment. Monitoring of vasculopathy remains challenging due to the lack of non-invasive biomarkers. Current treatment approaches provide variable benefit, but better understanding of the essential pathogenic mechanisms should help lead to improved outcomes. Whilst acknowledging that evidence is limited, this review aims to describe the vasculopathy of JDM in the context of pathophysiology, clinical features, and treatment of disease.
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Affiliation(s)
- Charalampia Papadopoulou
- Infection, Inflammation, and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Liza J McCann
- Department of Pediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
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