Outcome and prognostic factors in a French cohort of patients with myositis-associated interstitial lung disease

The Efficacy and Safety of Rituximab in Patients with Idiopathic Inflammatory Myopathy-Associated Interstitial Lung Disease: Case Series

Idiopathic inflammatory myopathy (IIM)-associated interstitial lung disease (ILD) is often rapidly progressive with a poor prognosis; however, no standard therapeutic regimen has been identified. This study aimed to investigate the efficacy and safety of rituximab in IIM-ILD patients. Five patients who had been administered rituximab for IIM-ILD at least once between August 2016 and November 2021 were included. Lung function decline was compared one year before and after rituximab. Disease progression, defined as a greater than 10% relative decline in forced vital capacity (FVC) compared to the baseline, was also compared before and after treatment. Adverse events were recorded for safety analysis. Five IIM-ILD patients received eight cycles. FVC-predicted values significantly decreased from 6 months before rituximab administration to those at the baseline (54.1% predicted (pre-6 months) vs. 48.5% predicted (baseline), p = 0.043); however, the FVC decline stabilized after rituximab. The rate of disease progression before rituximab showed a tendency to decrease after rituximab (75% (before) vs. 12.5% (6 months after, p = 0.059) vs. 14.3% (12 months after, p = 0.102)). Three adverse events developed, but none resulted in death. Rituximab can stabilize lung function decline with tolerable safety in Korean IIM patients with refractory ILD.

Analysis of risk factors of interstitial lung disease and mortality rates in Chinese patients with idiopathic inflammatory myopathy

Aim

To investigate the risk factors for interstitial lung disease (ILD) and prognosis in patients with idiopathic inflammatory myopathy (IIM).

Methods

A retrospective longitudinal study was performed in patients diagnosed with IIM between January 2012 and December 2018.

Results

The study cohort included 91 men and 195 women who were classified as having dermatomyositis (DM, n = 183), polymyositis (PM, n = 77), or clinical amyopathic DM (CADM, n = 26). ILD was identified in 46.5% (n = 133) of patients with IIM. The independent risk factors for ILD were age at disease onset, presence of anti‐Ro‐52 antibody, Gottron's papules, elevated serum immunoglobulin M levels and hypoalbuminemia. Older age at disease onset, ILD, malignancy, and increased serum aspartate aminotransferase and neutrophil‐to‐lymphocyte ratio (NLR) were identified as the independent predictors for mortality, whereas elevated serum albumin level was associated with a better prognosis. A total of 73 deaths (25.5%) occurred after a median follow‐up time of 33 months. Infection (49.3%) was the leading cause of death. In the overall cohort, the 1‐year, 5‐year and cumulative survival rates were 83.2%, 74.2% and 69.4%, respectively. The receiver operating characteristic curve indicated that the optimal cut‐off value of NLR for predicting death in IIM was 6.11.

Conclusion

IIM patients have a poor prognosis with substantial mortality, especially in patients who have older age at onset, ILD, malignancy and higher NLR. Close monitoring and aggressive therapies are required in patients having poor predictive factors.

Prognostic value of peripheral blood markers in patients with myositis-associated interstitial lung diseases

Objectives: The aim of this study was to investigate the association between survival of anti-MDA5 autoantibody-positive/negative patients with myositis-associated interstitial lung disease (MA-ILD) and neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), C-reactive protein-albumin ratio (CAR), and erythrocyte sedimentation rate-albumin ratio (EAR).Method: The study included 104 patients diagnosed with MA-ILD between January 2017 and February 2019 at the First Affiliated Hospital, University of Science and Technology of China. The clinical and laboratory results were compared between survivors and non-survivors in anti-MDA5 autoantibody-positive and anti-MDA5 autoantibody-negative patients. Cox proportional hazard models were used for univariable and multivariate analyses to determine survival-related factors. A logistic regression model was used to establish a joint diagnosis, and the feasibility of the combined diagnosis to evaluate the prognosis of MA-ILD was explored.Results: Among 47 anti-MDA5-positive patients with MA-ILD, EAR was an independent predictor of survival. When separated into high and low subgroups, high MLR (> 0.604) and EAR (> 1.458) were predictive of survival (p < 0.05). High MLR, high EAR, and age combined with lactate dehydrogenase were the highest (0.886) in predicting the prognosis of MA-ILD, and were higher than the area under the curve diagnosed separately. In 57 anti-MDA5-negative patients with MA-ILD, NLR and high EAR (> 0.872) were independent predictors of survival (p < 0.05).Conclusion: MLR and EAR are associated with prognosis in anti-MDA5-positive patients. NLR and EAR are associated with prognosis in anti-MDA5-negative patients. Using NLR, MLR, and EAR, inflammatory conditions of MA-ILD can be predicted and possible outcomes estimated.

Predictors and Mortality of Rapidly Progressive Interstitial Lung Disease in Patients With Idiopathic Inflammatory Myopathy: A Series of 474 Patients

Objective: This study was conducted to identify the characteristics and prognosis of rapidly progressive interstitial lung disease (RP-ILD) in idiopathic inflammatory myopathy (IIM) and to assess the predictors for poor survival of RP-ILD in IIM.

Methods: A total of 474 patients with IIM were enrolled retrospectively according to medical records from Peking University People's Hospital. Clinical and laboratory characteristics recorded at the diagnosis of patients with RP-ILD and chronic ILD (C-ILD) were compared. The Kaplan–Meier estimator and univariate and multivariate analyses were used for data analysis.

Results: ILD was identified in 65% (308/474) of patients with IIM. Patients with ILD were classified into two groups based on lung features: RP-ILD (38%, 117/308) and C-ILD (62%, 191/308). RP-ILD resulted in significantly higher mortality in IIM compared with C-ILD (27.4 vs. 7.9%, P < 0.05). In this study, by comparing IIM patients with and without RP-ILD, a list of initial predictors for RP-ILD development were identified, which included older age at onset, decreased peripheral lymphocytes, skin involvement (periungual erythema, skin ulceration, and subcutaneous/mediastinal emphysema), presence of anti-MDA5 antibody, serum tumor markers, etc. Further multivariate Cox proportional hazards model analysis identified that anti-MDA5 positivity was an independent risk factor for mortality due to RP-ILD (P < 0.05), and lymphocytes <30% in BALF might also be associated with poor survival of myositis-associated RP-ILD (P < 0.05).

Conclusion: Our study shows that RP-ILD results in increased mortality in IIM. Anti-MDA5 positivity and a lower lymphocyte ratio in BALF might be the predictive factor of mortality due to RP-ILD.

Interstitial Lung Disease in Polymyositis and Dermatomyositis

The idiopathic inflammatory myopathies (IIMs), including polymyositis (PM) and dermatomyositis (DM), are autoimmune connective tissue diseases with variable degrees of muscle inflammation and systemic involvement. Interstitial lung disease (ILD) is a common complication of the IIMs and is associated with increased mortality. Many patients with PM/DM have myositis-specific and myositis-associated antibodies (MSA/MAAs) that result in distinct clinical phenotypes. Among these MSAs, anti-aminoacyl-tRNA antibodies and anti-melanoma differentiation factor 5 antibodies have high rates of ILD. Corticosteroids are the mainstay of treatment, although the addition of other immunosuppressive therapy is typically necessary to achieve disease control.

Inflammatory Myopathy-Related Interstitial Lung Disease: From Pathophysiology to Treatment

Inflammatory myopathies (IM) are auto-immune connective tissue diseases characterized by muscle involvement and by extramuscular manifestations. As such, pulmonary manifestations, which mainly include interstitial lung disease (ILD), often darken two out of four distinct IM, namely dermatomyositis and overlapping myositis. Being the initiation site of the disease and being the leading cause of morbidity and mortality, ILD is of major importance in this context. ILD has a heterogeneous expression among the patients, with various onset mode, various radiological pattern, various severity and finally with different prognoses, which are particularly difficult to predict at the time of IM diagnosis. Therefore, ILD is a challenging issue. Treatments are based on steroids and immunosuppressive or targeted therapies. Their respective place is yet poorly codified however and remains often based on clinician expertise. Dedicated clinical trials are lacking to date and are also difficult to build, due to difficulty of constituting large and homogeneous patient groups and to rigorously evaluate disease outcomes. Indeed, pulmonary function tests alone are being regularly defeated in IM, in which respiratory muscles are often involved. Composite scores, bringing together several lung parameters, should thus be developed and validated in the future, to better assess the disease response to treatment. This review aims to describe the current knowledge of IM immuno-pathogenesis, the clinical features associated with IM related-ILD, focusing of both severity and prognosis, and the actual therapeutic approaches.

The Brazilian Society of Rheumatology recommendations on investigation and diagnosis of systemic autoimmune myopathies

BACKGROUND

This research is recommended by the Myopathy Committee of the Brazilian Society of Rheumatology for the investigation and diagnosis of systemic autoimmune myopathies. BODY: A systematic literature review was performed in the Embase, Medline (PubMed) and Cochrane databases, including studies published until October 2018. PRISMA was used for the review, and the articles were evaluated, based on the Oxford levels of evidence. Ten recommendations were developed addressing different aspects of systemic autoimmune myopathy investigation and diagnosis.

CONCLUSIONS

The European League Against Rheumatism/ American College of Rheumatology (EULAR/ACR) classification stands out for the diagnosis of systemic autoimmune myopathies. Muscular biopsy is essential, aided by muscular magnetic resonance images and electroneuromyography in complementary research. Analysis of the factors related to prognosis with the evaluation of extramuscular manifestations, and comorbidities and intense investigation regarding differential diagnoses are mandatory.

Management of Interstitial Lung Disease in Patients With Myositis Specific Autoantibodies

PURPOSE OF REVIEW

To review advances in the management of idiopathic inflammatory myopathy-associated interstitial lung disease (IIM-associated ILD) in the past 5 years, with highlights in myositis-specific antibody (MSA) groups.

RECENT FINDINGS

With the recent advent of widespread MSA testing, the study of specific homogeneous autoantibody-based subgroups of IIM-associated ILD is now possible. The prevalence, severity, prognosis, and response to treatment are under study for these individual MSAs. Early evidence suggests that PL-7- and PL-12-positive patients are more likely to have ILD and worse severity, compared to Jo-1 patients. Many medications have been efficacious for the treatment of IIM-associated ILD, including calcineurin inhibitors, rituximab, and cyclophosphamide. We suggest vigilant screening and monitoring of ILD in IIM patients with focus on the potential side effects associated with therapy and thus advocate appropriate vaccination, PCP prophylaxis, and bone health protection. Many different agents are used to manage patients with ILD with no comparative effectiveness studies to guide the clinician. The possibility of using MSAs to help guide treatment decisions is an appealing, although unproven, focus of research. Unfortunately, the rarity of non-Jo-1 myositis-specific antibodies has precluded robust study of response to treatment and overall management. Ongoing clinical trials and working groups are coordinating efforts to provide evidence-based management.