Immunological Biomarkers in Dermatomyositis

Updates on efficacy and safety janus kinase inhibitors in juvenile dermatomyositis

INTRODUCTION

Juvenile dermatomyositis (JDM) is a rare autoimmune disease most commonly with proximal weakness due to inflammation and characteristic skin rashes. Most patients have a chronic or polycyclic disease course on standard therapy so better treatments are needed. An interferon signature is well-established in key tissues of JDM. Janus kinase inhibitors (jakinibs), which can decrease IFN signaling, are therefore appealing as a targeted therapy.

AREAS COVERED

Herein is a review of the growing literature on JDM patients in jakinibs, including specifics of their jakinib exposure, summary of efficacy, disease features, and characteristics of patients treated, and safety parameters.

EXPERT OPINION

The vast majority of refractory JDM patients respond to jakinib therapy, though they have varied features, doses, and previous/concurrent medications, and data is largely retrospective. Jakinibs are an exciting and promising treatment in JDM. Evaluation with larger prospective controlled studies is needed to answer remaining questions about jakinibs in JDM regarding dosing, which JDM patients to treat with jakinibs, potential biomarkers to use, and how best to monitor safety risks in JDM.

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.

Relationship between Neutrophil-to-Lymphocyte Ratio and Systemic Lupus Erythematosus: A Meta-analysis

Systemic lupus erythematosus (SLE) is a chronic systematic autoimmune disease. Current methods of diagnosing SLE or evaluating its activity are complex and expensive. Numerous studies have suggested that neutrophil-to-lymphocyte ratio (NLR) is closely correlated with the presence of SLE and its activity, suggesting that it may serve as a diagnostic and monitoring indicator for SLE. Therefore, we performed a meta-analysis to systematically assess the association between NLR and SLE. We performed a literature search until 12 April 2019 in the PubMed, Web of Science, and China National Knowledge Infrastructure databases. Cross-sectional studies comparing the NLR of SLE patients versus those of healthy controls, of active versus inactive SLE patients, and of SLE patients with versus without lupus nephritis were considered for inclusion. Mean intergroup NLR differences were estimated using standardized mean differences and their 95% confidence intervals. Study quality was assessed using the Agency for Healthcare Research and Quality instrument for cross-sectional studies. Fourteen studies with 1,781 SLE patients and 1,330 healthy controls were included in this meta-analysis. The pooled results showed that the NLR was significantly higher in SLE patients than in healthy controls, in active SLE patients than in inactive SLE patients, and in SLE patients with lupus nephritis than in those without lupus nephritis. NLR may be an indicator for monitoring disease activity and reflecting renal involvement in SLE patients. Nevertheless, more high-quality studies are warranted to further validate our findings.

Guidelines of the Brazilian Society of Rheumatology for the treatment of systemic autoimmune myopathies

BACKGROUND

Recommendations of the Myopathy Committee of the Brazilian Society of Rheumatology for the management and therapy of systemic autoimmune myopathies (SAM).

MAIN BODY

The review of the literature was done in the search for the Medline (PubMed), Embase and Cochrane databases including studies published until June 2018. The Prisma was used for the systematic review and the articles were evaluated according to the levels of Oxford evidence. Ten recommendations were developed addressing the management and therapy of systemic autoimmune myopathies.

CONCLUSIONS

Robust data to guide the therapeutic process are scarce. Although not proven effective in controlled clinical trials, glucocorticoid represents first-line drugs in the treatment of SAM. Intravenous immunoglobulin is considered in induction for refractory cases of SAM or when immunosuppressive drugs are contra-indicated. Consideration should be given to the early introduction of immunosuppressive drugs. There is no specific period determined for the suspension of glucocorticoid and immunosuppressive drugs when individually evaluating patients with SAM. A key component for treatment in an early rehabilitation program is the inclusion of strength-building and aerobic exercises, in addition to a rigorous evaluation of these activities for remission of disease and the education of the patient and his/her caregivers.

Fashionably Late: A Case of Delayed Cutaneous Manifestations in Juvenile Dermatomyositis

Juvenile dermatomyositis (JDM) is a rare, but well recognized multi-systemic inflammatory myopathy in children defined by proximal muscle weakness and distinctive skin lesions, that if recognized and treated early result in decreased morbidity and mortality. The 1975 criteria established by Bohan and Peter center around the propensity for early development of heliotrope and Gottron’s lesions in combination with specific laboratory abnormalities, and are still the leading diagnostic tool. The following case demonstrates a toddler with an atypical presentation of JDM in which delayed dermatologic manifestations hindered initial diagnosis. A previously healthy 2 years and 11 months old female presented to the emergency department with a 7-month history of bilateral knee pain and progressive muscular weakness. Initial evaluation yielded a diagnosis of idiopathic rhabdomyolysis but progressive deterioration prompted additional workup. During her course of care, the patient required admission at numerous facilities for specialty procedures including swallow studies, electromyography, Nissen fundoplication with G-tube insertion, and eventual muscle biopsy, resulting in pathology clinching the diagnosis. Post-diagnosis the development of a heliotrope and malar rash ensued, 11 months after commencement of original presentation. As the Bohan and Peter criteria of 1975 can help to aid in diagnosis of JDM for textbook presentations, atypical cases such as ours suggest that revision to current diagnostic criteria needs to be established. Also, with many pediatric rheumatologists opting for less invasive methods than muscle biopsy to aid in diagnosis, in combination with the heterogeneous nature of currently tracked serous markers, the risk for delayed or missed diagnosis is amplified. As prior research has demonstrated, early diagnosis leads to better outcomes for children battling JDM. Therefore, it is vital that criteria be revised and additional research be conducted for more sensitive and specific markers to help aid in early diagnosis of JDM.

Update on outcome assessment in myositis

The adult and juvenile myositis syndromes, commonly referred to collectively as idiopathic inflammatory myopathies (IIMs), are systemic autoimmune diseases with the hallmarks of muscle weakness and inflammation. Validated, well-standardized measures to assess disease activity, known as core set measures, were developed by international networks of myositis researchers for use in clinical trials. Composite response criteria using weighted changes in the core set measures of disease activity were developed and validated for adult and juvenile patients with dermatomyositis and adult patients with polymyositis, with different thresholds for minimal, moderate and major improvement in adults and juveniles. Additional measures of muscle strength and function are being validated to improve content validity and sensitivity to change. A health-related quality of life measure, which incorporates patient input, is being developed for adult patients with IIM. Disease state criteria, including criteria for inactive disease and remission, are being used as secondary end points in clinical trials. MRI of muscle and immunological biomarkers are promising approaches to discriminate between disease activity and damage and might provide much-needed objective outcome measures. These advances in the assessment of outcomes for myositis treatment, along with collaborations between international networks, should facilitate further development of new therapies for patients with IIM.

Advances in biomarkers for dermatomyositis

Dermatomyositis (DM) and polymyositis (PM) are heterogeneous complex autoimmune diseases involving muscle damage. Patients with DM and PM display a wide spectrum of clinical manifestations and serological biomarkers, which may mislead and delay the proper diagnosis. Therefore, specific biomarkers or indicators for diagnosing DM and PM and monitoring disease activity are essential. Significant progress has been made through identifying novel serological biomarkers for DM and PM in recent years. Our aim is to focus on novel biomarkers for diagnosing and monitoring disease activity in DM and PM to highlight their predictive value and applicability in clinical practice.

Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio are 2 new inflammatory markers associated with pulmonary involvement and disease activity in patients with dermatomyositis

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have emerged as useful biomarkers to predict systemic inflammation. However, there is no study to investigate the relationship between the biomarkers and dermatomyositis (DM).

METHODS

Seventy-three newly diagnosed patients with DM and 147 healthy subjects were selected in this retrospective study. We divided the 73 DM patients into 2 groups: 55 without interstitial lung disease (ILD) and 18 with ILD. Complete clinical characteristics were extracted from the medical records of DM patients. The correlations between NLR, PLR, the clinical characteristics and the disease activity were analyzed.

RESULTS

For DM patients without ILD, the NLR and PLR were significantly higher than those in the control group (both P<0.001). For DM patients with ILD, the NLR and PLR were higher than in DM patients without ILD (P=0.004 and P=0.026, respectively). The NLR was positively correlated with C-reactive protein (CRP) (r=0.543, P<0.001) and the erythrocyte sedimentation rate (ESR) (r=0.513, P=0.001). The global activity scores correlated positively and significantly with NLR, PLR, and CRP (r=0.486, P<0.001; r=0.240, P=0.041; and r=0.343, P=0.003, respectively). Based on the ROC curve, to predict DM patients with ILD, the best cut-off value of the NLR was 3.98 (sensitivity 88.9%, specificity 52.7%, AUC=0.727), and the best cutoff value of PLR was 221.69 (sensitivity 77.8%, specificity 69.1%, AUC=0.722).

CONCLUSIONS

Both NLR and PLR exhibit favorable diagnostic performance in predicting pulmonary involvement and disease activity in patients with DM. We provide the optimal cut-off values for DM patients with ILD that would maximize the diagnostic efficiency.

Dysregulated innate immune function in the aetiopathogenesis of idiopathic inflammatory myopathies

The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of systemic muscle conditions that are believed to be autoimmune in nature. They have distinct pathological features, but the aetiopathogenesis of each subtype remains largely unknown. Recently, there has been increased interest in the complex role the innate immune system plays in initiating and perpetuating these conditions, and how this may differ between subtypes. This article summarises the traditional paradigms of IIM pathogenesis and reviews the accumulating evidence for disturbances in innate immune processes in these rare, but debilitating chronic conditions.