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Koumas C, Michelassi F. Immune-Mediated Necrotizing Myopathies: Current Landscape. Curr Neurol Neurosci Rep 2024; 24:141-150. [PMID: 38589696 DOI: 10.1007/s11910-024-01337-y] [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: 03/11/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Immune-mediated necrotizing myopathy (IMNM), characterized by acute or subacute onset, severe weakness, and elevated creatine kinase levels, poses diagnostic and therapeutic challenges. This article provides a succinct overview of IMNM, including clinical features, diagnostic strategies, and treatment approaches. RECENT FINDINGS Recent insights highlight the different clinical presentations and therapeutic options of IMNM stratified by autoantibody positivity and type. Additionally, recent findings call into question the reported link between statin use and IMNM. This review synthesizes current knowledge on IMNM, emphasizing its distinct clinical features and challenging management. The evolving understanding of IMNM underscores the need for a comprehensive diagnostic approach that utilizes a growing range of modalities. Early and aggressive immunomodulatory therapy remains pivotal. Ongoing research aims to refine diagnostic tools and therapeutic interventions for this challenging muscle disorder, underscoring the importance of advancing our understanding to enhance patient outcomes.
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Affiliation(s)
- Christoforos Koumas
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.
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2
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De Jesus AV, De Souza JM. Clinically amyopathic dermatomyositis associated with cutaneous ulcerations: a case-based review. Ann Med Surg (Lond) 2024; 86:1210-1214. [PMID: 38333314 PMCID: PMC10849458 DOI: 10.1097/ms9.0000000000001669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/20/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction and importance Dermatomyositis (DM) is an autoimmune myopathy primarily affecting both muscles and skin. When muscle weakness is not clinically apparent, but characteristic skin lesions are present, the condition is referred to as clinically amyopathic dermatomyositis (CADM). Case presentation The authors present the case of a 52-year-old female with a typical DM rash, interstitial pneumonia, and multiple skin ulcers. The skin biopsy was consistent with DM, and there were no signs of muscle involvement. Myositis-related and myositis-specific autoantibodies were also negative. Significant improvement was not observed until the patient received successive monthly pulses of methylprednisolone and the introduction of methotrexate. This treatment regimen allowed for the complete tapering of prednisone and resulted in sustained disease control. Clinical discussion In addition to the case presentation, a narrative literature review was conducted using the MEDLINE database, and an evidence-based treatment flowchart is proposed. CADM is a subtype of DM, related to higher incidences of interstitial lung disease, skin vasculopathy and malignancy. When ulcers or interstitial pneumonia are present, treatment should be early and aggressive. Active screening for neoplasms is recommended, particularly within the first 5 years. Conclusion The authors presented a case of seronegative CADM featuring skin vasculopathy, successfully treated with consecutive methylprednisolone pulses. Our literature review emphasized the importance of focused CADM management trials, highlighting the need for further research.
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Affiliation(s)
| | - Jean Marcos De Souza
- Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, Brazil
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3
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Dallevet CA, Benveniste O, Allenbach Y. Pathogenesis and Treatment in IMNM. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2023. [DOI: 10.1007/s40674-023-00201-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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Abdalla MS, Zhang Q, Abdalla MO, Abdel-Jalil SS. Statin-Induced Immune-Mediated Necrotizing Myopathy Resulting in Proximal Muscle Weakness. J Med Cases 2023; 14:64-70. [PMID: 36896367 PMCID: PMC9990704 DOI: 10.14740/jmc4039] [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: 01/28/2023] [Indexed: 02/27/2023] Open
Abstract
Statin-induced immune-mediated necrotizing myopathy (IMNM) is a subtype of IMNM linked to exposure to statins and is characterized by positive anti-hydroxymethylglutaryl (HMG) coenzyme A reductase (HMGCR) antibodies. Although rare, this entity has become increasingly recognized as a cause of proximal muscle weakness, especially with the widespread use of statin therapy. Unlike typical statin-associated muscle symptoms, IMNM myopathy often causes severe muscle injury, and muscle weakness persists or sometimes worsens following the withdrawal of statin therapy. Medical practitioners need to keep a high index of clinical suspicion for statin-induced IMNM in patients taking statins who present with muscle weakness. The disease can be debilitating, and treatment strategies are not well established despite the advances that have been made in the diagnosis. Here we present the clinical characteristics and disease course of two cases of statin-induced IMNM. Both patients presented with progressive proximal muscle weakness and myalgias while on long-term statin therapy without significant improvement in their symptoms following the withdrawal of statin therapy. IMNM was suspected, and both patients were found to have high titers of anti-HMG coenzyme A reductase antibodies and demonstrated microscopic features consistent with a diagnosis of IMNM on muscle biopsy. The patients experienced significant disability due to muscle weakness and required a protracted course of escalated immunosuppressive therapy. Although rare, IMNM should be suspected in patients taking statins who present with muscle weakness that fails to improve or worsens when statins were stopped. Early diagnosis and institution of immunosuppressive therapy are important to prevent the progression of the disease.
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Affiliation(s)
- Mohammed S Abdalla
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, IL, USA
| | - Qishuo Zhang
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, IL, USA
| | - Monzer O Abdalla
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, IL, USA
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Faria MSMS, Shinjo SK. COVID-19 as potential aggravating factor for the natural course of new onset-dermatomyositis. Reumatismo 2022; 74. [PMID: 35506321 DOI: 10.4081/reumatismo.2022.1440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 03/12/2022] [Indexed: 11/23/2022] Open
Abstract
Borges et al. have recently reported the first case of a dermatomyositis onset in close association with established coronavirus disease 2019 (COVID-19). Similarly, we report a patient who, on the contrary, had COVID-19 following early established dermatomyositis. We report prospectively the outcome of her disease.
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Affiliation(s)
- M S M S Faria
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP.
| | - S K Shinjo
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP.
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6
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Zeng R, Glaubitz S, Schmidt J. Antibody Therapies in Autoimmune Inflammatory Myopathies: Promising Treatment Options. Neurotherapeutics 2022; 19:911-921. [PMID: 35394612 PMCID: PMC9294121 DOI: 10.1007/s13311-022-01220-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/29/2022] Open
Abstract
Inflammatory myopathies, including polymyositis (PM), dermatomyositis (DM), inclusion body myositis (IBM), necrotizing myopathy (NM), antisynthetase syndrome (ASS) and overlap myositis (OM), in short myositis, are rare diseases. All forms of myositis have progressive muscle weakness in common, with each subtype characterized by different autoantibody profiles, histological findings and extramuscular manifestations. Due to better understanding of the pathogenesis of the muscle inflammation in myositis, new molecular pathways for targeted therapy have been discovered. Current therapies aim at different components of the innate or the adaptive immune response. Additionally, non-inflammatory mechanisms in myositis have come into focus as possible treatment targets. The use of therapeutical antibodies in myositis has been examined in various clinical studies, several of them randomized controlled ones: Depletion of B-cells by rituximab has been established as treatment of refractory myositis. IVIG, an antibody therapy in the wider sense, has now been licensed for DM following a recent positive clinical trial. Negative study results were reported in randomized trials with infliximab, sifalimumab and bimagrumab. Studies on basiliximab and eculizumab are currently underway, and are expected to yield results in a couple of years. Despite some promising results of clinical studies with antibody therapy in myositis, further research is crucial to optimize the treatment for this debilitating disease and to find treatment alternatives for treatment-refractory patients.
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Affiliation(s)
- Rachel Zeng
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Stefanie Glaubitz
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany.
- Department of Neurology and Pain Treatment, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany.
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany.
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7
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Kocoloski A, Martinez S, Moghadam-Kia S, Lacomis D, Oddis CV, Ascherman DP, Aggarwal R. Role of Intravenous Immunoglobulin in Necrotizing Autoimmune Myopathy. J Clin Rheumatol 2022; 28:e517-e520. [PMID: 34581697 DOI: 10.1097/rhu.0000000000001786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Immune-mediated necrotizing myopathy (IMNM) is a subtype of myositis that is associated with a refractory phenotype and poorer prognosis. The aim of the study was to provide single large center experience of outcomes of intravenous immunoglobulin (IVIg) for patients with IMNM using longitudinally collected data. METHODS This case series longitudinally evaluated 4 of the 6 myositis core set measures at baseline and at 3 and 6 months after IVIg on 20 adult IMNM patients from 2014 to 2019 at the University of Pittsburgh. We assessed patients for improvement in core set measures, prednisone dose, adverse effects, and by the "limited" ACR/EULAR 2016 myositis response criteria. The mean differences in CK and manual muscle testing (MMT-8) were compared using a paired t test. A clinically significant response was defined as a >10% absolute improvement in the MMT-8 and a >50% absolute reduction in serum CK at 6 months of IVIg. RESULTS Intravenous immunoglobulin treatment was associated with marked improvement in IMNM patients, with 85% of patient meeting clinically significant response. The median (interquartile range) relative percent improvement in CK level was 96% (85%-98%) and in MMT was 29% (14%-36%) at 6 months.There was a significant reduction in the mean (SD) dose of prednisone at 6 months and had minimal adverse effects. In addition, with IVIg, most (13/14) patients had at least minimal improvement as per ACR/EULAR 2016 myositis response criteria. CONCLUSIONS Based on objective, meaningful improvement in MMT-8 and CK as well as marked reduction in prednisone doses with acceptable tolerability, early implementation of IVIg should be considered in adult IMNM.
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Affiliation(s)
- Amanda Kocoloski
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - Silvia Martinez
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - Siamak Moghadam-Kia
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - David Lacomis
- Departments of Neurology and Pathology (Neuropathology), University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Chester V Oddis
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - Dana P Ascherman
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - Rohit Aggarwal
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
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8
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Wang JX, Wilkinson M, Oldmeadow C, Limaye V, Major G. Outcome Predictors of Immune-Mediated Necrotising Myopathy-A Retrospective, Multicentre Study. Rheumatology (Oxford) 2022; 61:3824-3829. [PMID: 35022671 PMCID: PMC9434226 DOI: 10.1093/rheumatology/keac014] [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: 09/01/2021] [Revised: 12/27/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Evidence-based treatment protocols are currently lacking for immune-mediated necrotising myopathy. In this multicentre retrospective study, we examined baseline clinical characteristics and treatment variables that may predict short-term outcome of patients with immune-mediated necrotising myopathy. METHODS Muscle biopsies from the John Hunter Hospital and the Royal Adelaide Hospital obtained between 2012 and 2019 were reviewed at a single laboratory at South Australia Pathology. All biopsies with histological features of IMNM were identified. Demographics of study subjects, clinical information, and myositis-specific antibody status were recorded along with muscle strength, serum CK and treatment regimens at baseline, three and six months. Primary outcome measures were muscle strength and serum creatinine kinase at 3- and 6-months. Mixed-effects regression models in a Bayesian framework were performed using Statistical Package R. RESULTS Female sex, older age, initial prednisone dose and intravenous methylprednisolone were associated with greater improvement in serum creatine kinase. In patients with moderate-to-severe disease at baseline, early intravenous immunoglobulin was associated with greater improvement in hip flexor strength at six months. CONCLUSION Early IVIg was associated with clinical improvement in short-term follow-up in IMNM. Female sex, older age, initial oral prednisone dose and initial use of IV methylprednisolone were associated with better biochemical improvement.
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Affiliation(s)
- Jeremy X Wang
- Department of Rheumatology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Michael Wilkinson
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Vidya Limaye
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Gabor Major
- Department of Rheumatology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia.,Faculty of Medicine, University of Newcastle, Newcastle, New South Wales, Australia
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Truzzi NCC, Hoff LS, Borges IBP, de Souza FHC, Shinjo SK. Clinical manifestations, outcomes, and antibody profile of Brazilian adult patients with dermatomyositis: a single-center longitudinal study. Adv Rheumatol 2022; 62:41. [PMID: 36371389 PMCID: PMC9660096 DOI: 10.1186/s42358-022-00276-x] [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: 06/20/2022] [Accepted: 10/29/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Currently, only a few retrospective cohort or cross-sectional studies have described the general characteristics of Brazilian patients with classical dermatomyositis (DM). In contrast, we aimed to longitudinally assess a large sample of these patients, and several myositis autoantibodies. METHODS This single-center longitudinal study included 91 Brazilian adults with defined DM (EULAR/ACR 2017) who underwent follow-up appointments in our tertiary center from 2012 to 2021. Myositis autoantibody analysis was performed using a commercial kit. RESULTS The mean age of the patients was 47.3 ± 15.4 years, with a predominance of female (67.0%) and White (81.3%) patients. As an initial treatment, 76.9% of the patients received methylprednisolone pulse therapy, 59.3% received intravenous immunoglobulin, and 54.9% received both drugs. The median follow-up duration was 44 months (interquartile 17-67) months. There were 92 severe episodes of infection, and neoplasms were identified in 20 patients (22.0%). Hypertension was identified in 46.2% of patients, whereas diabetes mellitus and myocardial infarction occurred in 19.8% and 4.4%, respectively. Nine patients died during the follow-up. At the last visit, one-third of the patients had disease activity, half had a complete clinical response, and one-fifth were in disease remission. In a univariate logistic regression, anti-aminoacyl-tRNA synthetase antibodies (n = 13) were associated with interstitial lung disease, "mechanic's hands", and anti-Ro-52, and had an inverse association with "V"-neck and "shawl" signs. Anti-MDA-5 (n = 10) were associated with male gender, digital ulcers, vasculitis, arthritis, anti-Ro-52, and active disease. Anti-Ro-52 (n = 26) were associated with "mechanics' hands", arthritis, interstitial lung disease, anti-tRNA synthetases, and anti-MDA-5. No association was found for anti-Mi-2 (n = 10). CONCLUSIONS This study shows the general profile of a significant sample of Brazilian patients with DM as well as the association of some antibodies with clinical and laboratory manifestations of this myositis.
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Affiliation(s)
- Natássia Cristina Carboni Truzzi
- grid.11899.380000 0004 1937 0722Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Av. Dr. Arnaldo, 455, 3º Andar, sala 3184 - Cerqueira César, Sao Paulo, SP CEP: 01246-903 Brazil
| | - Leonardo Santos Hoff
- grid.441906.e0000 0004 0603 3487Division of Rheumatology, Faculdade de Medicina, Universidade Potiguar (UnP), Natal, RN Brazil
| | - Isabela Bruna Pires Borges
- grid.11899.380000 0004 1937 0722Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Av. Dr. Arnaldo, 455, 3º Andar, sala 3184 - Cerqueira César, Sao Paulo, SP CEP: 01246-903 Brazil
| | - Fernando Henrique Carlos de Souza
- grid.11899.380000 0004 1937 0722Division of Rheumatology, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, SP Brazil
| | - Samuel Katsuyuki Shinjo
- grid.11899.380000 0004 1937 0722Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Av. Dr. Arnaldo, 455, 3º Andar, sala 3184 - Cerqueira César, Sao Paulo, SP CEP: 01246-903 Brazil
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Abstract
Idiopathic inflammatory myopathies (IIM), also known as myositis, are a heterogeneous group of autoimmune disorders with varying clinical manifestations, treatment responses and prognoses. Muscle weakness is usually the classical clinical manifestation but other organs can be affected, including the skin, joints, lungs, heart and gastrointestinal tract, and they can even result in the predominant manifestations, supporting that IIM are systemic inflammatory disorders. Different myositis-specific auto-antibodies have been identified and, on the basis of clinical, histopathological and serological features, IIM can be classified into several subgroups - dermatomyositis (including amyopathic dermatomyositis), antisynthetase syndrome, immune-mediated necrotizing myopathy, inclusion body myositis, polymyositis and overlap myositis. The prognoses, treatment responses and organ manifestations vary among these groups, implicating different pathophysiological mechanisms in each subtype. A deeper understanding of the molecular pathways underlying the pathogenesis and identifying the auto-antigens of the immune reactions in these subgroups is crucial to improving outcomes. New, more homogeneous subgroups defined by auto-antibodies may help define disease mechanisms and will also be important in future clinical trials for the development of targeted therapies and in identifying biomarkers to guide treatment decisions for the individual patient.
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Goswami RP, Haldar SN, Chatterjee M, Vij P, van der Kooi AJ, Lim J, Raaphorst J, Bhadu D, Gelardi C, Danieli MG, Kumar U. Efficacy and safety of intravenous and subcutaneous immunoglobulin therapy in idiopathic inflammatory myopathy: A systematic review and meta-analysis. Autoimmun Rev 2021; 21:102997. [PMID: 34800685 DOI: 10.1016/j.autrev.2021.102997] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis on the efficacy and safety of intravenous (IVIg) and subcutaneous (SCIg) immunoglobulin (Ig) therapy in the treatment of idiopathic inflammatory myopathy (IIM) and juvenile dermatomyositis (JDM). METHODS PubMed, Embase and SCOPUS were searched to identify studies on Ig therapy in patients with IIM and/or JDM (2010-2020). Outcome measures were complete response (CR) or partial response (PR) in terms of muscle power and extramuscular disease activity measures on the International Myositis Assessment and Clinical Studies Group (IMACS) core set domains. RESULTS Twenty-nine studies were included (n = 576, 544 IIM, 32 JDM). Muscle power PR with pooled Ig therapy was 88.5% (95% confidence interval (CI): 80.6-93.5, n = 499) and PR with SCIg treatment was 96.61% (95% CI: 87.43-99.15, n = 59). Pooled PR with first-line use of IVIg was 77.07% (95% CI: 61.25-92.89, n = 80). Overall, mean time to response was 2.9 months (95% CI: 1.9-4.1). Relapse was seen in 22.76% (95% CI: 14.9-33). Studies on cutaneous disease activity and dysphagia showed significant treatment responses. Glucocorticoid and immunosuppressant sparing effect was seen in 40.9% (95% CI: 20-61.7) and 42.2% (95% CI: 20.4-64.1) respectively. Ig therapy was generally safe with low risk of infection (1.37%, 95% CI: 0.1-2.6). CONCLUSIONS Add-on Ig therapy improves muscle strength in patients with refractory IIM, but evidence on Ig therapy in new-onset disease and extramuscular disease activity is uncertain.
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Affiliation(s)
- Rudra Prosad Goswami
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
| | - Soumendra Nath Haldar
- Department of Medicine and Microbiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Moumita Chatterjee
- Department of Mathematics and Statistics, Aliah University, Kolkata, India.
| | - Pallavi Vij
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
| | - Anneke J van der Kooi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, PO Box 22660, 1100DD Amsterdam, the Netherlands.
| | - Johan Lim
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, PO Box 22660, 1100DD Amsterdam, the Netherlands.
| | - Joost Raaphorst
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, PO Box 22660, 1100DD Amsterdam, the Netherlands.
| | - Danveer Bhadu
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
| | - Chiara Gelardi
- Emergency Medicine, AziendaOspedaliera Marche Nord, Fano, PU 61032, Italy
| | - Maria Giovanna Danieli
- Clinica Medica, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Torrette di Ancona 60020, Italy.
| | - Uma Kumar
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
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Zeng R, Glaubitz S, Schmidt J. Inflammatory myopathies: shedding light on promising agents and combination therapies in clinical trials. Expert Opin Investig Drugs 2021; 30:1125-1140. [PMID: 34779311 DOI: 10.1080/13543784.2021.2003776] [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] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Due to new insights into the pathogenesis of inflammatory myopathies - in short myositis - and the urgent need for new treatment options in patients who are refractory to standard therapy, multiple novel drugs have been developed and studied in clinical trials. In light of this exciting development, a critical evaluation of the present data is necessary in order to identify the best pathway to future treatment of inflammatory myopathies. AREAS COVERED This review focuses on the current evidence from clinical trials in myositis and encompasses dermatomyositis, polymyositis, necrotizing myopathy, antisynthetase-syndrome, overlap myositis, and inclusion body myositis. The results of studies on new therapeutic agents are summarized, in particular larger cohort studies and randomized trials from recent years. When such data were not available, earlier and smaller representative studies were included instead. EXPERT OPINION Current studies in most myositis subtypes have shown positive effects of novel biologicals such as abatacept, sifalimumab, JAK-Inhibitors as well as known agents such as rituximab, but further studies are needed to confirm these observations. In inclusion body myositis, the eagerly awaited recent therapeutic trials have missed their primary endpoints, except for the phase 2 study with rapamycin, which has demonstrated significant improvements in secondary endpoints. Future trials will also need to focus on combination therapies of multiple immunomodulatory agents.
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Affiliation(s)
- Rachel Zeng
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Stefanie Glaubitz
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany.,Department of Neurology and Pain Treatment, University Hospital of the Medical School Brandenburg, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany.,Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
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13
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Unger L. Therapieoptionen und outcome bei idiopathischen entzündlichen Muskelerkrankungen. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1423-7579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungDie idiopathischen entzündlichen Muskelerkrankungen (IIM) sind eine sehr heterogene Gruppe, die sich immer besser differenzieren lässt. Damit eröffnen sich mehr Möglichkeiten für gezieltere Therapien, die zum einen auf die Veränderung pathogenetischer Faktoren gerichtet sind. Zum anderen sollen sie Krankheitsaktivität vermindern, Muskelaufbau fördern, Organschäden verhindern und Lebensqualität verbessern.Die folgende Übersichtsarbeit fasst die vorhandenen Daten zu bereits angewandten Behandlungen in der Praxis zusammen und gibt einen Ausblick auf zukünftige Alternativen.Für die Polymyositis (PM) und Dermatomyositis (DM) sind Glukokortikoide weiter unverzichtbarer Therapiebestandteil. Eine frühe Kombination mit konventionellen DMARDs hat sich durchgesetzt. Die ProDerm- Studie stellt für die Immunglobulintherapie in der Praxis eine gute Basis dar. Rituximab (RTX) löst Cyclophosphamid (CYC) bei schweren Verlaufsformen immer mehr ab.Für Abatacept, Jak-Kinase-Hemmer, Apremilast, Sifalimumab und Lenabasum müssen vielversprechende erste Ergebnisse durch weiter Studien untermauert werden. Anspruchsvoll ist die Behandlung bei extramuskulärer Beteiligung. Von großem Interesse ist der zukünftige Stellenwert von Nintedanib bei der interstitiellen Lungenerkrankung im Rahmen einer Myositis (IIM-ILD).Die Therapie der Einschlusskörperchen- Myositis (IBM) ist immer noch eine große Herausforderung. Zahlreiche Studien haben bisher nicht überzeugend zu einer Besserung der Prognose führen können. Spätestens bei therapierefraktärem Verlauf sollte an eine Malignom- assoziierte Myositis gedacht werden. Gelegentlich verbirgt sich auch eine hereditäre Myopathie hinter einer, zum Beispiel durch einen Infekt oder Überlastung getriggerten, Myositis.Komplikationen im Verlauf, wie Dysphagie, Infektionen, Myokardbeteiligung stellen keine Seltenheit dar. Häufig besteht Multimorbidität. Eine interdisziplinäre Zusammenarbeit in einem kompetenten Team, in dem erfahrene Physio-, Ergo- und Psychotherapeuten fester Bestandteil sind, ist unabdingbar für eine erfolgreiche Begleitung dieser Patienten.
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Affiliation(s)
- Leonore Unger
- Städtisches Klinikum Dresden, I. Medizinische Klinik, Dresden, Deutschland
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Hoff LS, de Souza FHC, Miossi R, Shinjo SK. Long-term effects of early pulse methylprednisolone and intravenous immunoglobulin in patients with dermatomyositis and polymyositis. Rheumatology (Oxford) 2021; 61:1579-1588. [PMID: 34302454 DOI: 10.1093/rheumatology/keab597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the long-term effects of pulse intravenous methylprednisolone (IVMP) or intravenous immunoglobulin (IVIG) administered during the first year of diagnosis in dermatomyositis (DM) and polymyositis (PM) patients. METHODS This is a retrospective single-center cohort study of patients with DM/PM followed for up to 4 years from 2001 to 2017. We used Cox regression models to estimate hazard ratios (HRs) and assess the effects of early pulse IVMP or IVIG on 3 outcomes: complete clinical response, corticosteroid discontinuation, and survival. Analysis was adjusted for clinical, laboratory, and treatment covariates. RESULTS A total of 204 patients were included and categorized into 4 initial treatment groups: pulse IVMP (n = 46), pulse IVMP+IVIG (n = 55), IVIG (n = 10), and without IVMP or IVIG (n = 93). The groups of early pulse IVMP and pulse IVMP+IVIG had a higher HR for complete clinical response in the multivariate models (HR = 1.56, 95% CI = 1.05-2.33, p = 0.029; and HR = 1.58, 95% CI = 1.02-2.45, p = 0.041, respectively). Only the group of pulse IVMP+IVIG had a significant association with corticosteroid discontinuation in the multivariate analysis (HR = 1.65, 95% CI = 1.02-2.68, p = 0.043). Early pulse IVMP or IVIG had no impact on mortality. CONCLUSION Despite having a more severe disease profile, patients with DM/PM submitted to pulse IVMP or pulse IVMP+IVIG during the first year of diagnosis had a higher HR for complete clinical response, whereas the combination of pulse IVMP+IVIG had an association with corticosteroid discontinuation. Prospective long-term studies are warranted to confirm these benefits of early pulse IVMP and IVIG on patients with DM/PM.
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Affiliation(s)
- Leonardo S Hoff
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil (BR).,School of Medicine, Universidade Potiguar (UnP), Natal, Brazil (BR)
| | | | - Renata Miossi
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil (BR)
| | - Samuel K Shinjo
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil (BR)
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Monitoring disease activity and damage in adult and juvenile idiopathic inflammatory myopathy. Curr Opin Rheumatol 2020; 32:553-561. [PMID: 32890032 DOI: 10.1097/bor.0000000000000749] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW We have reviewed the literature to identify significant advances related to disease activity and damage in the idiopathic inflammatory myopathies (IIMs) from January 2019 to July 2020. RECENT FINDINGS New observations in the field from 2019 to 2020 have resulted in a better understanding of the clinical association and pathogenic origins of IIM. The use of patient-reported outcome measures and perspectives, identifying biomarkers and making better use of autoantibody testing are summarized. Basic sciences have led to an improved understanding of the role of NETosis in calcinosis, and of interferon type 1, in IIM. Preliminary insights are offered into Covid-19 in the setting of IIM, and the use of potential tools for monitoring disease remotely, which may assume larger importance for optimal disease management during a global pandemic. The wider exploration of newer imaging modalities and the use of nailfold capillaroscopy is a further step in better management of the condition. SUMMARY The summarized research in IIM is a step forward in being able to further define, and to distinguish disease activity from damage, in order to potentially aid future clinical diagnosis and management in this challenging disease.
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