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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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Rastegar TF, Khan IA, Christopher-Stine L. Decoding the Intricacies of Statin-Associated Muscle Symptoms. Curr Rheumatol Rep 2024:10.1007/s11926-024-01143-y. [PMID: 38575845 DOI: 10.1007/s11926-024-01143-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE OF REVIEW Hyperlipidemia is the major cardiovascular morbidity and mortality risk factor. Statins are the first-line treatment for hyperlipidemia. Statin-associated muscle symptoms (SAMS) are the main reason for the discontinuation of statins among patients. The purpose of this review is to guide clinicians to recognize the difference between self-limited and autoimmune statin myopathy in addition to the factors that potentiate them. Finally, treatment strategies will be discussed. This review mostly focuses on new data in the past 3 years. RECENT FINDINGS Recent findings suggest that SAMS is a complex and multifactorial condition that involves mitochondrial dysfunction, oxidative stress, and immune-mediated mechanisms. Effective management of SAMS requires a thorough evaluation of the patient's symptoms, risk factors, and medication history, as well as consideration of alternative treatment options. While statins are effective in reducing the risk of cardiovascular events, their use is associated with a range of adverse effects, including SAMS.
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Affiliation(s)
- Tara Fallah Rastegar
- Johns Hopkins Myositis Center, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Imtiaz Ahmed Khan
- Department of Internal Medicine, Texas Tech University Health Science Center, Amarillo, TX, USA
| | - Lisa Christopher-Stine
- Johns Hopkins Myositis Center, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Khoo T, Chinoy H. Anti-HMGCR immune-mediated necrotising myopathy: Addressing the remaining issues. Autoimmun Rev 2023; 22:103468. [PMID: 37884200 DOI: 10.1016/j.autrev.2023.103468] [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: 10/02/2023] [Accepted: 10/23/2023] [Indexed: 10/28/2023]
Abstract
The discovery of autoantibodies directed against the 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) enzyme has defined a sub-set of immune-mediated necrotising myopathy (IMNM) which is strongly associated with exposure to statin medications. Although understanding of anti-HMGCR IMNM has grown considerably with the reporting of multiple cohorts in North America, Europe, Asia and Oceania, there remain many unanswered questions. The true incidence of anti-HMGCR IMNM is not known and heterogeneity of phenotype and treatment response within this autoantibody sub-group is being increasingly recognised. Statin-naïve adults and juvenile patients with anti-HMGCR potentially share characteristics distinct from statin-exposed patients, alluding to unique pathogenesis. Conflicting data exists on whether malignancies are associated with anti-HMGCR and further clarification is required to determine the degree of cancer screening required. Treatment approaches to anti-HMGCR IMNM are heterogeneous but generally highlight the efficacy of intravenous immunoglobulin. Even with multimodal immunosuppression, patients with anti-HMGCR remain prone to relapse, with younger patients generally manifesting more refractory disease. In this Review, we aim to summarise the current literature on anti-HMGCR and discuss the remaining issues.
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Affiliation(s)
- Thomas Khoo
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, South Australia, Australia; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom.
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom
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Yamamoto S, Yoshida A, Gono T, Kuwana M. The Role of Environmental Factors in the Development of Idiopathic Inflammatory Myopathies: a Narrative Review. Curr Rheumatol Rep 2023; 25:264-275. [PMID: 37971581 DOI: 10.1007/s11926-023-01120-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW This review aims to evaluate recent findings on the role of environmental factors in the development and clinical presentation of idiopathic inflammatory myopathies (IIMs). RECENT FINDINGS A targeted literature review was conducted to identify reports relevant to the association between environmental factors and IIMs published over the past three years. There has been an increasing number of publications dealing with the association of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or vaccination with the development of IIMs, highlighting the significant role of the antiviral immune response in the pathogenesis of the disease. Traditional environmental factors associated with the pathogenic process of IIM subclassifications included drugs such as statins and immune checkpoint inhibitors, ultraviolet radiation, smoking, air pollutants, and vitamin D deficiency. Correlations of seasonality and residence with the onset of certain IIM subtypes suggest a potential role of environmental triggers in the pathogenic process. An interplay between genetic predisposition and various environmental factors might contribute to the development of IIMs as well as the heterogeneous clinical and serological presentation of IIMs. The growing evidence on the role of environmental factors in the development of IIMs provides important clues to elucidate the pathophysiology of these disease entities. The mechanisms underlying the interactions between genetic predisposition and environmental factors should be investigated in the future.
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Affiliation(s)
- Shintaro Yamamoto
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Akira Yoshida
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan.
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan.
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Khoo T, Lilleker JB, Thong BYH, Leclair V, Lamb JA, Chinoy H. Epidemiology of the idiopathic inflammatory myopathies. Nat Rev Rheumatol 2023; 19:695-712. [PMID: 37803078 DOI: 10.1038/s41584-023-01033-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of systemic autoimmune diseases that affect the skeletal muscles and can also involve the skin, joints, lungs and heart. The epidemiology of IIM is obscured by changing classification criteria and the inherent shortcomings of case identification using healthcare record diagnostic coding. The incidence of IIM is estimated to range from 0.2 to 2 per 100,000 person-years, with prevalence from 2 to 25 per 100,000 people. Although the effects of age and gender on incidence are known, there is only sparse understanding of ethnic differences, particularly in indigenous populations. The incidence of IIM has reportedly increased in the twenty-first century, but whether this is a genuine increase is not yet known. Understanding of the genetic risk factors for different IIM subtypes has advanced considerably. Infections, medications, malignancy and geography are also commonly identified risk factors. Potentially, the COVID-19 pandemic has altered IIM incidence, although evidence of this occurrence is limited to case reports and small case series. Consideration of the current understanding of the epidemiology of IIM can highlight important areas of interest for future research into these rare diseases.
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Affiliation(s)
- Thomas Khoo
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - James B Lilleker
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neuroscience, Manchester Academic Health Science Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valérie Leclair
- Department of Medicine, Division of Rheumatology, McGill University, Montreal, Canada
| | - Janine A Lamb
- Epidemiology and Public Health Group, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.
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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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Muruganandam M, Iqbal A, Akpan EB, Dolomisiewicz AC, Waters YM, Emil NS, Nunez SE, McElwee MK, O'Sullivan FX, Fields RA, Sibbitt WL. Statin-associated immune-mediated necrotizing myositis in Native Americans. Rheumatology (Oxford) 2022; 61:4855-4862. [PMID: 35348616 DOI: 10.1093/rheumatology/keac198] [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: 11/17/2021] [Revised: 03/16/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Statin-associated immune-mediated necrotizing myopathy (IMNM) and idiopathic inflammatory myositis (IIM) are myopathies with overlapping features. This study compared the manifestations of IMNM to IIM in Native Americans. METHOD Twenty-one Native American patients with inflammatory myopathy (IM) were characterized as to diabetes mellitus, hyperlipidaemia, statin exposure, myopathy diagnosis, muscle histology, autoimmune and myositis-specific autoantibodies, therapy and outcome. RESULTS IM consisted of 52.4% IMNM, 42.9% IIM and 4.8% metabolic myopathy. IMNM vs IIM patients were older [61.6 years (s.d. 9.8) vs 39.8 (14.3)], diabetes mellitus (100% vs 55.6%), hyperlipidaemia (100% vs 33.3%), statin-exposure (100% vs 22.2%), creatine kinase [CK; 11 780 IU (s.d. 7064) vs 1707 (1658)], anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) antibodies (85.7% vs 11.1%) and necrotizing IM (81.8% vs 11.1%), but shorter disease duration [26.2 months (s.d. 395) vs 78.4 (47.9)], RP (9.1% vs 55.6%), cutaneous manifestations (0% vs 55.6%), ANA (18.2% vs 66.7%) or any autoantibody (18.2% vs 88.9%) (all P < 0.05). MRI abnormalities, histologic IM, myositis-specific autoantibodies, pulmonary hypertension, oesophageal dysfunction, interstitial lung disease, disability and persistently elevated CK were similar. IMNM vs IIM was treated more with IVIG (72.7% vs 11.1%; P = 0.009) and less with antimetabolites (45.5% vs 88.9%; P = 0.05) and rituximab (18.2% vs 55.6%; P = 0.09). CONCLUSIONS IMNM may occur in Native Americans and is associated with diabetes mellitus, hyperlipidaemia, statin use and older age and is characterized by marked CK elevation, necrotizing myopathy and anti-HMGCR antibodies with few cutaneous or vascular manifestations.
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Affiliation(s)
- Maheswari Muruganandam
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Ahsan Iqbal
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Eyerusalem B Akpan
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Anthony C Dolomisiewicz
- Department of Internal Medicine, Division of Rheumatology and Immunology, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, USA
| | - Yvonne M Waters
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - N Suzanne Emil
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Sharon E Nunez
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Matthew K McElwee
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Frank X O'Sullivan
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Roderick A Fields
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Wilmer L Sibbitt
- Department of Internal Medicine, Division of Rheumatology and School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
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Che WI, Lundberg IE, Holmqvist M. Environmental Risks for Inflammatory Myopathies. Rheum Dis Clin North Am 2022; 48:861-874. [PMID: 36333000 DOI: 10.1016/j.rdc.2022.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is an up-to-date review on external environmental factors for adult-onset idiopathic inflammatory myopathies (IIMs). Environmental factors with suggestive evidence including ultraviolet radiation, smoking, infectious agents (viruses in particular), pollutants, medications (ie, statin) and vitamin D deficiency are discussed. We also discuss the potential implications of environmental factors in IIM development, identify current challenges, and provide insight into future investigations.
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Affiliation(s)
- Weng Ian Che
- Department of Medicine, Solna, Eugeniahemmet, T2, Karolinska Universitetssjukhuset, Solna, Stockholm 171 76, Sweden; Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid E Lundberg
- Rheumatology, Karolinska University Hospital, Anna Steckséns gata 30A, Stockholm 171 76, Sweden; Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; ME Gastro, Derm and Rheuma, Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden.
| | - Marie Holmqvist
- Department of Medicine, Solna, Eugeniahemmet, T2, Karolinska Universitetssjukhuset, Solna, Stockholm 171 76, Sweden; Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Rheumatology, Karolinska University Hospital, Anna Steckséns gata 30A, Stockholm 171 76, Sweden; Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Wei J, Ketner E, Mammen AL. Increased risk of statin-associated autoimmune myopathy among American Indians. Arthritis Rheumatol 2022; 74:1602-1603. [PMID: 35333459 PMCID: PMC9531600 DOI: 10.1002/art.42126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/27/2022] [Accepted: 02/19/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Jennie Wei
- Gallup Indian Medical Center, Gallup, NM
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Damoiseaux J, Mammen AL, Piette Y, Benveniste O, Allenbach Y. 256th ENMC international workshop: Myositis specific and associated autoantibodies (MSA-ab): Amsterdam, The Netherlands, 8-10 October 2021. Neuromuscul Disord 2022; 32:594-608. [DOI: 10.1016/j.nmd.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
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