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Conti F, Moratti M, Leonardi L, Catelli A, Bortolamedi E, Filice E, Fetta A, Fabi M, Facchini E, Cantarini ME, Miniaci A, Cordelli DM, Lanari M, Pession A, Zama D. Anti-Inflammatory and Immunomodulatory Effect of High-Dose Immunoglobulins in Children: From Approved Indications to Off-Label Use. Cells 2023; 12:2417. [PMID: 37830631 PMCID: PMC10572613 DOI: 10.3390/cells12192417] [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] [Received: 08/07/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND The large-scale utilization of immunoglobulins in patients with inborn errors of immunity (IEIs) since 1952 prompted the discovery of their key role at high doses as immunomodulatory and anti-inflammatory therapy, in the treatment of IEI-related immune dysregulation disorders, according to labelled and off-label indications. Recent years have been dominated by a progressive imbalance between the gradual but constant increase in the use of immunoglobulins and their availability, exacerbated by the SARS-CoV-2 pandemic. OBJECTIVES To provide pragmatic indications for a need-based application of high-dose immunoglobulins in the pediatric context. SOURCES A literature search was performed using PubMed, from inception until 1st August 2023, including the following keywords: anti-inflammatory; children; high dose gammaglobulin; high dose immunoglobulin; immune dysregulation; immunomodulation; immunomodulatory; inflammation; intravenous gammaglobulin; intravenous immunoglobulin; off-label; pediatric; subcutaneous gammaglobulin; subcutaneous immunoglobulin. All article types were considered. IMPLICATIONS In the light of the current imbalance between gammaglobulins' demand and availability, this review advocates the urgency of a more conscious utilization of this medical product, giving indications about benefits, risks, cost-effectiveness, and administration routes of high-dose immunoglobulins in children with hematologic, neurologic, and inflammatory immune dysregulation disorders, prompting further research towards a responsible employment of gammaglobulins and improving the therapeutical decisional process.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Arianna Catelli
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Elisa Bortolamedi
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Emanuele Filice
- Department of Pediatrics, Maggiore Hospital, 40133 Bologna, Italy;
| | - Anna Fetta
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marianna Fabi
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Facchini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Maria Elena Cantarini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Angela Miniaci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
| | - Duccio Maria Cordelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Daniele Zama
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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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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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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Orandi AB, Fotis L, Lai J, Morris H, White AJ, French AR, Baszis KW. Favorable outcomes with reduced steroid use in juvenile dermatomyositis. Pediatr Rheumatol Online J 2021; 19:127. [PMID: 34404425 PMCID: PMC8369654 DOI: 10.1186/s12969-021-00615-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/14/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND High-intensity glucocorticoid regimens are commonly used to induce and maintain remission in Juvenile Dermatomyositis but are associated with several adverse side-effects. Evidence-based treatment guidelines from North American and European pediatric rheumatology research societies both advocate induction with intravenous pulse steroids followed by high dose oral steroids (2 mg/kg/day), which are then tapered. This study reports the time to disease control with reduced glucocorticoid dosing. METHODS We retrospectively reviewed the records at a single tertiary-care children's hospital of patients diagnosed with Juvenile Dermatomyositis between 2000 and 2014 who had a minimum of 2 years of follow-up. The primary outcome measure was time to control of muscle and skin disease. Additional outcome measures included glucocorticoid dosing, effect of treatment on height, frequency of calcinosis, and complications from treatment. RESULTS Of the 69 patients followed during the study period, 31 fulfilled inclusion criteria. Median length of follow-up was 4.58 years, (IQR 3-7.5). Myositis control was achieved in a median of 7.1 months (IQR 0.9-63.4). Cutaneous disease control was achieved in a median of 16.7 months (IQR 4.3-89.5). The median starting dose of glucocorticoids was 0.85 mg/kg/day, (IQR 0.5-1.74). The median duration of steroid treatment was 9.1 months, (IQR 4.7-17.4), while the median duration of any pharmacotherapy was 29.2 months (IQR 10.4 to 121.3). Sustained disease control off medications was achieved in 21/31 (68%) patients by the end of review. Persistent calcinosis was identified in only one patient (3%). CONCLUSION Current accepted treatment paradigms for Juvenile Dermatomyositis include oral glucocorticoids beginning at 2 mg/kg/day and reduced over a prolonged time period. However, our results suggest that treatment using reduced doses and duration with early use of steroid-sparing agents is comparably effective in achieving favorable outcomes in Juvenile Dermatomyositis.
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Affiliation(s)
- Amir B. Orandi
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA ,grid.66875.3a0000 0004 0459 167XPresent Address: Department of Pediatric and Adolescent Medicine, Division of Pediatric Rheumatology, Mayo Clinic, Rochester, MN USA
| | - Lampros Fotis
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA ,grid.5216.00000 0001 2155 0800Present Address: Department of Pediatrics, Division of Pediatric Rheumatology, National and Kapodistrian University of Athens, Athens, Greece
| | - Jamie Lai
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA ,grid.39382.330000 0001 2160 926XPresent Address: Department of Pediatrics, Division of Pediatric Rheumatology, Baylor College of Medicine, Houston, TX USA
| | - Hallie Morris
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA ,grid.253615.60000 0004 1936 9510Present Address: Division of Neonatology, George Washington University School of Medicine and Health Science, Washington, D.C, USA
| | - Andrew J. White
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
| | - Anthony R. French
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
| | - Kevin W. Baszis
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
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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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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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Orandi AB, Dharnidharka VR, Al-Hammadi N, Baszis KW. Clinical phenotypes and biologic treatment use in juvenile dermatomyositis-associated calcinosis. Pediatr Rheumatol Online J 2018; 16:84. [PMID: 30594206 PMCID: PMC6311016 DOI: 10.1186/s12969-018-0299-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few risk factors have been identified for the development of calcinosis among patients with Juvenile Dermatomyositis, and currently no clinical phenotype has been associated with its development. We analyzed a large database of patients to further elucidate any relationships among patients with and without calcinosis. METHOD The CARRA legacy registry recruited pediatric rheumatology patients from 55 centers across North America from 2010 through 2014, including over 650 subjects with Juvenile Dermatomyositis. We compared the demographic characteristics, clinical disease features and treatment histories of those with and without calcinosis using univariate and multivariate logistic regression. RESULTS Of the 631 patients included in the analysis, 84 (13%) had a current or prior history of calcinosis. These patients were statistically more likely to have longer durations of disease prior to diagnosis and treatment, have lipodystrophy and joint contractures, and to have received intravenous immune globulin or rituximab as treatments. CONCLUSIONS Calcinosis is found more often in patients with prolonged active disease, severe disease, and certain clinical features such as lipodystrophy and joint contractures. When these factors are combined with other known associations and predictors, groups of at-risk patients can be more effectively identified, treated and studied to improve overall outcomes.
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Affiliation(s)
- Amir B. Orandi
- 0000 0004 0459 167Xgrid.66875.3aDivision of Pediatric Rheumatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902 USA ,Division of Pediatric Rheumatology, Department of Pediatrics, St. Louis, MO USA
| | | | - Noor Al-Hammadi
- 0000 0001 2355 7002grid.4367.6Division of Biostatistics, Washington University School of Medicine, St. Louis, MO USA
| | - Kevin W. Baszis
- Division of Pediatric Rheumatology, Department of Pediatrics, St. Louis, MO USA
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Abstract
The idiopathic inflammatory myopathies of childhood consist of a heterogeneous group of autoimmune diseases characterised by proximal muscle weakness and pathognomonic skin rashes. The overall prognosis of juvenile myositis has improved significantly over recent years, but the long-term outcome differs substantially from patient to patient, suggestive of distinct clinical phenotypes with variable responses to treatment. High doses of corticosteroids remain the cornerstone of therapy along with other immunosuppressant therapies depending on disease severity and response. The advent of biological drugs has revolutionised the management of various paediatric rheumatologic diseases, including inflammatory myopathies. There are few data from randomised controlled trials to guide management decisions; thus, several algorithms for the treatment of juvenile myositis have been developed using international expert opinion. The general treatment goals now include elimination of active disease and normalisation of physical function, so as to preserve normal growth and development, and to prevent long-term damage and deformities. This review summarises the newer and possible future therapies of juvenile inflammatory myopathies, including evidence supporting their efficacy and safety.
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Anh-Tu Hoa S, Hudson M. Critical review of the role of intravenous immunoglobulins in idiopathic inflammatory myopathies. Semin Arthritis Rheum 2016; 46:488-508. [PMID: 27908534 DOI: 10.1016/j.semarthrit.2016.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this review was to summarize key findings from the literature concerning the therapeutic role of intravenous immunoglobulins (IVIg) in idiopathic inflammatory myopathies (IIM), dissecting the evidence according to disease subtype and treatment indication, and to review the evidence relating to the mechanism of action of IVIg in IIM to ascertain rationale for continued research. METHODS Medline (Ovid) and Pubmed databases were searched from inception to July 2016 using relevant keywords. Original and review articles were retrieved for full-text review. Bibliographies of selected articles were also hand-searched for additional references. Data were summarized qualitatively and in tabular form. RESULTS The efficacy of IVIg in IIM is supported by 3 randomized controlled trials, involving dermatomyositis and polymyositis subjects, in refractory, relapsed, or steroid-dependent disease, as well as part of first-line therapy in elderly dermatomyositis subjects. Other indications for IVIg are supported by uncontrolled evidence only. Limitations of studies include open, uncontrolled or retrospective study designs, small and selected samples, short-term follow-up and ad hoc outcome measures. Despite the limited evidence, there is strong biological plausibility for the role of IVIg in IIM. CONCLUSION Robust, controlled evidence to support the use of IVIg using validated outcome measures is urgently required to guide therapeutic decision-making and maximize outcomes in IIM.
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Affiliation(s)
- Sabrina Anh-Tu Hoa
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marie Hudson
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
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Fasano S, Alves SC, Isenberg DA. Current pharmacological treatment of idiopathic inflammatory myopathies. Expert Rev Clin Pharmacol 2016; 9:547-558. [PMID: 26708717 DOI: 10.1586/17512433.2016.1136561] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The idiopathic inflammatory myopathies are uncommon and heterogeneous disorders. Their classification is based on distinct clinicopathologic features. Although idiopathic inflammatory myopathies share some similarities, different subtypes may have variable responses to therapy, so it is very important to distinguish the correct subtype. There are few randomised, double blind placebo controlled studies to support the current treatment. High dose corticosteroids continue to be the first-line therapy and other immunosupressive drugs are used in refractory cases, as well as steroid-sparing agents. Some novel therapeutic approaches have emerged as potential treatment including tacrolimus, intravenous immunoglobulin and rituximab, following good outcomes reported in case studies. However, more randomised controlled trials are needed. This review considers the current and the potential future therapies for inflammatory myopathies.
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Affiliation(s)
- Serena Fasano
- a Rheumatology Unit, Department of Clinical and Experimental Medicine , Second University of Naples , Naples , Italy
| | - Sara Custódio Alves
- b Internal Medicine Unit, Department of Medicine , Hospital de Cascais , Cascais , Portugal
| | - David A Isenberg
- c Centre for Rheumatology, Department of Medicine , University College London , London , UK
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Hamada M, Tanaka I, Sakurai Y, Hosono Y, Mimori T. Juvenile polymyositis associated with anti-OJ (anti-isoleucyl-tRNA synthetase) autoantibody in a 13-year-old girl. Mod Rheumatol 2015; 27:541-544. [DOI: 10.3109/14397595.2015.1014137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Masaaki Hamada
- Department of Pediatrics, Yao Municipal Hospital, Osaka, Japan
| | - Ichiro Tanaka
- Department of Pediatrics, Yao Municipal Hospital, Osaka, Japan
| | - Yoshihiko Sakurai
- Department of Pediatrics, Matsubara Tokushukai Hospital, Osaka, Japan
| | - Yuji Hosono
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tsuneyo Mimori
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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12
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Clinical course and outcomes of Iranian children with juvenile dermatomyositis and polymyositis. Clin Rheumatol 2014; 33:1113-8. [PMID: 24878926 DOI: 10.1007/s10067-014-2675-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 05/09/2014] [Accepted: 05/12/2014] [Indexed: 12/23/2022]
Abstract
This study evaluated the clinical features, course, and outcomes of Iranian children with juvenile dermatomyositis (JDM), juvenile polymyositis (JPM), and other uncommon connective tissue disorders. A chart review of 85 Iranian children with JDM and JPM was performed during a 10-year period from 2003 to 2013. The patients' clinical signs and symptoms, laboratory data, and other factors affecting clinical outcomes were recorded using questionnaires. Statistical analysis was performed using SPSS software version 20. In all, 40 boys and 45 girls were included in the study (F/M, 1.1:1). Disease frequency was significantly higher in boys aged <5 years (F/M, 0.4:1) and girls aged >5 years (F/M, 1.6:1). The combined mean age at diagnosis was 7.5 years. Muscle weakness, particularly in the proximal muscles of lower extremities (96 %); fatigue (83 %); and heliotrope rash (71 %) were the most frequently recorded symptoms. Elevated lactate dehydrogenase level was the most common enzyme disturbance (98 %). Monocyclic course was seen in 60 % of patients. The mean treatment duration was 3 years. The incidence rate of complications such as calcinosis, lipodystrophy, and growth disturbances was 20, 9, and 30 %, respectively. The occurrence of these complications in patients with monocyclic disease was significantly lower. Vital organ involvement led to the death of four patients. The incidence of calcinosis was significantly lower in patients having a shorter interval between disease onset and treatment. Two important complications, failure to thrive and lipodystrophy, were significantly higher in patients having antinuclear antibodies. The incidence of the above three complications was higher in patients with polycyclic or continuous chronic disease. Respiratory failure was the most common cause of patient mortality.
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Hasija R, Pistorio A, Ravelli A, Demirkaya E, Khubchandani R, Guseinova D, Malattia C, Canhao H, Harel L, Foell D, Wouters C, De Cunto C, Huemer C, Kimura Y, Mangge H, Minetti C, Nordal EB, Philippet P, Garozzo R, Martini A, Ruperto N. Therapeutic approaches in the treatment of juvenile dermatomyositis in patients with recent-onset disease and in those experiencing disease flare: an international multicenter PRINTO study. ACTA ACUST UNITED AC 2013; 63:3142-52. [PMID: 21647864 DOI: 10.1002/art.30475] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate response to therapy over a 24-month period in a large prospective international cohort of patients with juvenile dermatomyositis (DM). METHODS The study included 145 patients with recent-onset juvenile DM and 130 juvenile DM patients experiencing disease flare, all of whom were <18 years old. Disease activity parameters and therapeutic approaches in 4 geographic areas were analyzed at baseline and at 6, 12, and 24 months. Response was assessed according to the Pediatric Rheumatology International Trials Organization (PRINTO) juvenile DM response criteria, and data were reported "as observed" and in the intent-to-treat (ITT) population. RESULTS Patients with recent-onset juvenile DM at baseline had higher baseline disease activity and greater improvement over 24 months when compared to juvenile DM patients experiencing disease flare at baseline. Methotrexate (MTX) or high-dose corticosteroids were administered more frequently to patients with recent-onset juvenile DM, compared to juvenile DM patients experiencing disease flare, who were more likely to receive cyclosporine. Compared to patients from Western and Eastern Europe, a higher proportion of patients from South and Central America and North America received pulse steroids, and the average steroid dosage was higher in the North American and South and Central American patients. The use of MTX was similar in all 4 regions, while cyclosporin A was more frequently used in Western Europe. In the "as observed" analysis, 57.9% of the patients with recent-onset juvenile DM and 36.4% of the patients experiencing disease flare (P<0.001) reached at least a 70% response by PRINTO criteria at 6 months; these proportions had increased at month 24 to 78.4% and 51.2%, respectively (P<0.001). Corresponding results of the ITT analysis were much lower, with only one-third of the patients able to maintain the initial assigned therapy over 24 months. CONCLUSION Patients with recent-onset juvenile DM are more likely to achieve significant clinical improvement over 24 months, when compared to patients experiencing flares of juvenile DM. Internationally, various therapeutic approaches are used to treat this disease.
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Albayda J, Christopher-Stine L. Novel approaches in the treatment of myositis and myopathies. Ther Adv Musculoskelet Dis 2012; 4:369-77. [PMID: 23024713 DOI: 10.1177/1759720x12447705] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The inflammatory myopathies are a heterogeneous group of disorders characterized by muscle weakness and inflammation. Although no standard therapeutic guidelines exist, traditional treatment has included corticosteroids and a variety of second-line immunosuppressants. As treatment of refractory disease has been difficult, newer agents and approaches have been used with varying response. The advent of standardized treatment response criteria by the International Myositis Assessment and Clinical Studies (IMACS) group has helped investigators to evaluate and compare clinical trial outcomes in a more rigorous fashion. The use of intravenous immunoglobulin (IVIG), rituximab, biologic agents including tumor necrosis factor (TNF) inhibitors, stem-cell transplantation, gene therapy, and vascular occlusion resistance training are reviewed here. As our understanding of disease pathogenesis at the immunologic, genetic, and molecular level expands, the discovery of novel therapeutic targets hold promise for the successful treatment of these conditions.
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Affiliation(s)
- Jemima Albayda
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
OPINION STATEMENT Autoimmune neuromuscular disorders in childhood include Guillain-Barré syndrome and its variants, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), juvenile myasthenia gravis (JMG), and juvenile dermatomyositis (JDM), along with other disorders rarely seen in childhood. In general, these diseases have not been studied as extensively as they have been in adults. Thus, treatment protocols for these diseases in pediatrics are often based on adult practice, but despite the similarities in disease processes, the most widely used treatments have different effects in children. For example, some of the side effects of chronic steroid use, including linear growth deceleration, bone demineralization, and chronic weight issues, are more consequential in children than in adults. Although steroids remain a cornerstone of therapy in JDM and are useful in many cases of CIDP and JMG, other immunomodulatory therapies with similar efficacy may be used more frequently in some children to avoid these long-term sequelae. Steroids are less expensive than most other therapies, but chronic steroid therapy in childhood may lead to significant and costly medical complications. Another example is plasma exchange. This treatment modality presents challenges in pediatrics, as younger children require central venous access for this therapy. However, in older children and adolescents, plasma exchange is often feasible via peripheral venous access, making this treatment more accessible than might be expected in this age group. Intravenous immunoglobulin also is beneficial in several of these disorders, but its high cost may present barriers to its use in the future. Newer steroid-sparing immunomodulatory agents, such as azathioprine, tacrolimus, mycophenolate mofetil, and rituximab, have not been studied extensively in children. They show promising results from case reports and retrospective cohort studies, but there is a need for comparative studies looking at their relative efficacy, tolerability, and long-term adverse effects (including secondary malignancy) in children.
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Affiliation(s)
- Hugh J. McMillan
- Division of Neurology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario Canada
| | - Basil T. Darras
- Department of Neurology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Peter B. Kang
- Department of Neurology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
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Lorenzoni PJ, Scola RH, Kay CSK, Prevedello PG, Espíndola G, Werneck LC. Idiopathic inflammatory myopathies in childhood: a brief review of 27 cases. Pediatr Neurol 2011; 45:17-22. [PMID: 21723454 DOI: 10.1016/j.pediatrneurol.2011.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 11/24/2010] [Accepted: 01/24/2011] [Indexed: 11/29/2022]
Abstract
The most common idiopathic inflammatory myopathies in children include juvenile dermatomyositis, juvenile polymyositis, and myositis associated with another autoimmune disease (overlap myositis). Idiopathic inflammatory myopathies manifest different characteristics affecting children. Only a few investigations of childhood idiopathic inflammatory myopathies were reported, involving 27 patients. In addition, clinical findings, serum muscular enzyme levels, results of electromyography studies, muscle biopsy features, and treatment responses were studied. Seventeen female and 10 male were classified as exhibiting juvenile dermatomyositis (n = 19), juvenile polymyositis (n = 6), or overlap myositis (n = 2). Overlap myositis was associated with systemic sclerosis and systemic erythematous lupus. The mean age at onset was 6.1 years for juvenile dermatomyositis, 4.9 years for juvenile polymyositis, and 8.5 years for overlap myositis. The most common signs included proximal weakness and myalgia. The serum creatine kinase level was increased in 48.2% of patients. An electromyography study revealed myopathic features in 85% of patients. Muscle biopsies led to observations of inflammatory infiltrates with preferential perivascular involvement in the juvenile dermatomyositis group, and endomysial involvement in the juvenile polymyositis group. Fiber atrophy was predominantly perifascicular in the juvenile dermatomyositis group. Treatment with prednisone improved the findings in 81.5% of children.
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Affiliation(s)
- Paulo José Lorenzoni
- Neuromuscular Disorders Unit, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil
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