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Johnson SR, Bernstein EJ, Bolster MB, Chung JH, Danoff SK, George MD, Khanna D, Guyatt G, Mirza RD, Aggarwal R, Allen A, Assassi S, Buckley L, Chami HA, Corwin DS, Dellaripa PF, Domsic RT, Doyle TJ, Falardeau CM, Frech TM, Gibbons FK, Hinchcliff M, Johnson C, Kanne JP, Kim JS, Lim SY, Matson S, McMahan ZH, Merck SJ, Nesbitt K, Scholand MB, Shapiro L, Sharkey CD, Summer R, Varga J, Warrier A, Agarwal SK, Antin-Ozerkis D, Bemiss B, Chowdhary V, Dematte D'Amico JE, Hallowell R, Hinze AM, Injean PA, Jiwrajka N, Joerns EK, Lee JS, Makol A, McDermott GC, Natalini JG, Oldham JM, Saygin D, Lakin KS, Singh N, Solomon JJ, Sparks JA, Turgunbaev M, Vaseer S, Turner A, Uhl S, Ivlev I. 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) Guideline for the Treatment of Interstitial Lung Disease in People with Systemic Autoimmune Rheumatic Diseases. Arthritis Care Res (Hoboken) 2024; 76:1051-1069. [PMID: 38973731 DOI: 10.1002/acr.25348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/18/2024] [Accepted: 04/09/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE We provide evidence-based recommendations regarding the treatment of interstitial lung disease (ILD) in adults with systemic autoimmune rheumatic diseases (SARDs). METHODS We developed clinically relevant population, intervention, comparator, and outcomes questions. A systematic literature review was then performed, and the available evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. A panel of clinicians and patients reached consensus on the direction and strength of the recommendations. RESULTS Thirty-five recommendations were generated (including two strong recommendations) for first-line SARD-ILD treatment, treatment of SARD-ILD progression despite first-line ILD therapy, and treatment of rapidly progressive ILD. The strong recommendations were against using glucocorticoids in systemic sclerosis-ILD as a first-line ILD therapy and after ILD progression. Otherwise, glucocorticoids are conditionally recommended for first-line ILD treatment in all other SARDs. CONCLUSION This clinical practice guideline presents the first recommendations endorsed by the American College of Rheumatology and American College of Chest Physicians for the treatment of ILD in people with SARDs.
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Affiliation(s)
- Sindhu R Johnson
- University of Toronto, Schroeder Arthritis Institute, Toronto Western Hospital, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Elana J Bernstein
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York City
| | | | | | - Sonye K Danoff
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | - Hassan A Chami
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | - Tracy M Frech
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison
| | - John S Kim
- University of Virginia School of Medicine, Charlottesville
| | | | - Scott Matson
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | - Ross Summer
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Didem Saygin
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
| | - Ilya Ivlev
- Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
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Johnson SR, Bernstein EJ, Bolster MB, Chung JH, Danoff SK, George MD, Khanna D, Guyatt G, Mirza RD, Aggarwal R, Allen A, Assassi S, Buckley L, Chami HA, Corwin DS, Dellaripa PF, Domsic RT, Doyle TJ, Falardeau CM, Frech TM, Gibbons FK, Hinchcliff M, Johnson C, Kanne JP, Kim JS, Lim SY, Matson S, McMahan ZH, Merck SJ, Nesbitt K, Scholand MB, Shapiro L, Sharkey CD, Summer R, Varga J, Warrier A, Agarwal SK, Antin-Ozerkis D, Bemiss B, Chowdhary V, Dematte D'Amico JE, Hallowell R, Hinze AM, Injean PA, Jiwrajka N, Joerns EK, Lee JS, Makol A, McDermott GC, Natalini JG, Oldham JM, Saygin D, Lakin KS, Singh N, Solomon JJ, Sparks JA, Turgunbaev M, Vaseer S, Turner A, Uhl S, Ivlev I. 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) Guideline for the Treatment of Interstitial Lung Disease in People with Systemic Autoimmune Rheumatic Diseases. Arthritis Rheumatol 2024; 76:1182-1200. [PMID: 38978310 DOI: 10.1002/art.42861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/18/2024] [Accepted: 04/09/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVE We provide evidence-based recommendations regarding the treatment of interstitial lung disease (ILD) in adults with systemic autoimmune rheumatic diseases (SARDs). METHODS We developed clinically relevant population, intervention, comparator, and outcomes questions. A systematic literature review was then performed, and the available evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. A panel of clinicians and patients reached consensus on the direction and strength of the recommendations. RESULTS Thirty-five recommendations were generated (including two strong recommendations) for first-line SARD-ILD treatment, treatment of SARD-ILD progression despite first-line ILD therapy, and treatment of rapidly progressive ILD. The strong recommendations were against using glucocorticoids in systemic sclerosis-ILD as a first-line ILD therapy and after ILD progression. Otherwise, glucocorticoids are conditionally recommended for first-line ILD treatment in all other SARDs. CONCLUSION This clinical practice guideline presents the first recommendations endorsed by the American College of Rheumatology and American College of Chest Physicians for the treatment of ILD in people with SARDs.
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Affiliation(s)
- Sindhu R Johnson
- University of Toronto, Schroeder Arthritis Institute, Toronto Western Hospital, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Elana J Bernstein
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York City
| | | | | | - Sonye K Danoff
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | - Hassan A Chami
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | - Tracy M Frech
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison
| | - John S Kim
- University of Virginia School of Medicine, Charlottesville
| | | | - Scott Matson
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | - Ross Summer
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Didem Saygin
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
| | - Ilya Ivlev
- Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
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Kawaguchi T, Matsuda M, Umekita K, Miyazaki T. Treatment with low-dose nintedanib and tacrolimus in patients with progressive fibrosing interstitial lung diseases with anti-ARS antibody-positive dermatomyositis. Respirol Case Rep 2024; 12:e01428. [PMID: 38983609 PMCID: PMC11231737 DOI: 10.1002/rcr2.1428] [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: 06/05/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024] Open
Abstract
Nintedanib has been demonstrated to inhibit the rate of forced vital capacity decline in patients with progressive fibrosing interstitial lung diseases (PF-ILD) at a dose of 200 or 300 mg/day in the INBUILD trial. Although concomitant use of nintedanib with P-glycoprotein inhibitors reportedly increases the plasma concentrations of the former, tacrolimus, a P-glycoprotein inhibitor, is often used to treat connective tissue diseases-related interstitial lung diseases. The optimal dose of nintedanib in combination with tacrolimus for the treatment of PF-ILD with connective tissue disease is unknown. We herein present two patients with PF-ILD with anti-aminoacyl-tRNA synthetase antibody-positive dermatomyositis who were successfully treated with low-dose nintedanib (<200 mg/day) in combination with tacrolimus.
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Affiliation(s)
- Takeshi Kawaguchi
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Motohiro Matsuda
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Kunihiko Umekita
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Taiga Miyazaki
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine University of Miyazaki Miyazaki Japan
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Yang X, Cui X, Yang X, Ren B, Cheng X, Zhao X, Liu S, Tian T, Zhao H, Qu L, Li X. Liver Involvement is Associated with Higher Risk of Rapidly Progressive Interstitial Lung Disease and Mortality in Anti-Melanoma Differentiation-Associated Gene 5 Antibody- Positive Dermatomyositis. J Inflamm Res 2024; 17:3101-3113. [PMID: 38774443 PMCID: PMC11108061 DOI: 10.2147/jir.s462721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/07/2024] [Indexed: 05/24/2024] Open
Abstract
Purpose This study aimed to assess liver involvement and investigate its correlation with rapidly progressive interstitial lung disease (RP-ILD) and mortality in anti-melanoma differentiation-associated gene 5 antibody-positive (anti-MDA5 positive) DM patients. Patients and Methods This retrospective study included 159 patients diagnosed with anti-MDA5 positive DM or anti-synthetase syndrome (ASyS). Clinical features and laboratory findings were compared between patients with anti-MDA5 positive DM and patients with ASyS. In the anti-MDA5 positive DM cohort, clinical features and laboratory findings between patients with liver involvement and without liver involvement were further compared. The effects of liver involvement on the overall survival (OS) and development of RP-ILD were also analyzed using Kaplan-Meier method and Cox regression analysis. Results Levels of serum aspartate aminotransferase (AST), alanine transaminase (ALT), γ-glutamyl transferase (γGT) and alkaline phosphatase (ALP) were all significantly higher in patients with anti-MDA5 positive DM than those in patients with ASyS. In our cohort of anti-MDA5 positive DM patents, 31 patients (34.4%) were complicated with liver involvement. Survival analysis revealed that serum ferritin >1030.0 ng/mL (p<0.001), ALT >103.0 U/l (p<0.001), AST >49.0 U/l (p<0.001), γGT >82.0 U/l (p<0.001), ALP >133.0 U/l (p<0.001), lactate dehydrogenase (LDH)>474.0 U/l (p<0.001), plasma albumin (ALB) <35.7 g/l (p<0.001) and direct bilirubin (DBIL) >2.80 μmol/l (p=0.002) predicted poor prognosis. The incidence of RP-ILD increased remarkably in patients with liver involvement compared to patients without liver involvement (58.1% vs 22.0%, p=0.001). Multivariate analysis revealed that elevated serum ALT level was an independent risk factor for mortality (HR 6.0, 95% CI 2.3, 16.2, p<0.001) and RP-ILD (HR 5.9, 95% CI 2.2, 15.9, p<0.001) in anti-MDA5 positive DM patents. Conclusion Liver involvement is common in patients with anti-MDA5 positive DM. Elevated serum ALT level was an independent risk factor for RP-ILD and mortality in patients with anti-MDA5 positive DM.
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Affiliation(s)
- Xin Yang
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Xiaoguang Cui
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Xiao Yang
- Scientific Research Center and Precision Medical Institute, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Bincheng Ren
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Xiaojing Cheng
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Xinrui Zhao
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Shanshan Liu
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Tian Tian
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Hui Zhao
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Li Qu
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
| | - Xueyi Li
- Department of Rheumatology, Xi’an Jiaotong University Second Affiliated Hospital, Xi’an, People’s Republic of China
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Shan DM, Gupta N, Ortega‐Loayza AG, Shea S, Nandan A. Anti-nuclear matrix protein 2 antibody-positive amyopathic dermatomyositis presenting in a patient with prostate cancer: A case report. Clin Case Rep 2024; 12:e8884. [PMID: 38725932 PMCID: PMC11079545 DOI: 10.1002/ccr3.8884] [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: 02/17/2024] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
Nuclear matrix protein (NXP-2) positive amyopathic dermatomyositis (DM) may present without classic symptoms like muscle weakness, dysphagia, and edema, and mimic conditions like cutaneous lupus. Given DM's association with malignancy and interstitial lung disease, prompt and accurate diagnosis is important. Testing for myositis-specific antibodies aids diagnosis in ambiguous cases.
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Affiliation(s)
- Divya M. Shan
- School of MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Neha Gupta
- Division of Rheumatology, Allergy and ImmunologyVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | | | - Sofia Shea
- DermatopathologyHunter Holmes McGuire Veterans Affairs Medical CenterRichmondVirginiaUSA
| | - Abhishek Nandan
- Division of Rheumatology, Allergy and ImmunologyVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
- RheumatologyHunter Holmes McGuire Veterans Affairs Medical CenterRichmondVirginiaUSA
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Jeong E, Hong H, Lee YA, Kim KS. Potential Rheumatoid Arthritis-Associated Interstitial Lung Disease Treatment and Computational Approach for Future Drug Development. Int J Mol Sci 2024; 25:2682. [PMID: 38473928 PMCID: PMC11154459 DOI: 10.3390/ijms25052682] [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] [Received: 01/22/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by swelling in at least one joint. Owing to an overactive immune response, extra-articular manifestations are observed in certain cases, with interstitial lung disease (ILD) being the most common. Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is characterized by chronic inflammation of the interstitial space, which causes fibrosis and the scarring of lung tissue. Controlling inflammation and pulmonary fibrosis in RA-ILD is important because they are associated with high morbidity and mortality. Pirfenidone and nintedanib are specific drugs against idiopathic pulmonary fibrosis and showed efficacy against RA-ILD in several clinical trials. Immunosuppressants and disease-modifying antirheumatic drugs (DMARDs) with anti-fibrotic effects have also been used to treat RA-ILD. Immunosuppressants moderate the overexpression of cytokines and immune cells to reduce pulmonary damage and slow the progression of fibrosis. DMARDs with mild anti-fibrotic effects target specific fibrotic pathways to regulate fibrogenic cellular activity, extracellular matrix homeostasis, and oxidative stress levels. Therefore, specific medications are required to effectively treat RA-ILD. In this review, the commonly used RA-ILD treatments are discussed based on their molecular mechanisms and clinical trial results. In addition, a computational approach is proposed to develop specific drugs for RA-ILD.
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Affiliation(s)
- Eunji Jeong
- Department of Medicine, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea;
| | - Hyunseok Hong
- Yale College, Yale University, New Haven, CT 06520, USA;
- Department of Clinical Pharmacology and Therapeutics, School of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Yeon-Ah Lee
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea;
| | - Kyoung-Soo Kim
- Department of Medicine, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea;
- Department of Clinical Pharmacology and Therapeutics, School of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea
- East-West Bone & Joint Disease Research Institute, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
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7
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Sevim E, Kobrin D, Casal-Dominguez M, Pinal-Fernandez I. A comprehensive review of dermatomyositis treatments - from rediscovered classics to promising horizons. Expert Rev Clin Immunol 2024; 20:197-209. [PMID: 37842905 DOI: 10.1080/1744666x.2023.2270737] [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: 07/25/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Dermatomyositis (DM) is a rare inflammatory disease with diverse cutaneous and systemic manifestations, often associated with myositis-specific antibodies. Managing patients with refractory DM, or individuals presenting pecific complications, like calcinosis or rapidly progressive interstitial lung disease, presents unique challenges. AREAS COVERED This review explores current and promising treatment options for DM, drawing from clinical studies, case series, and case reports that consider the underlying disease pathophysiology. EXPERT OPINION Recent advancements have improved our understanding and management of DM. The discovery of distinct DM autoantibodies and their correlation with specific clinical phenotypes has transformed patient categorization and enhanced our knowledge of the pathogenesis of the disease. Intravenous immunoglobulin, a well-established treatment in dermatomyositis, has regained prominence and a large randomized clinical trial has reaffirmed its efficacy, confirming it as an effective therapeutic option in this group of patients. Identification of the type I interferon pathway as a key pathogenic mechanism in DM has opened up new avenues for more effective treatment strategies. Blocking the JAK/STAT pathway offers potential for improved management of refractory patients and prevention of highly morbid complications. These recent advancements have significantly impacted the management and care of dermatomyositis patients, enabling tailored approaches, targeted interventions, and improved outcomes for individuals affected by this complex condition.
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Affiliation(s)
- Ecem Sevim
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Dale Kobrin
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Maria Casal-Dominguez
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iago Pinal-Fernandez
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Suzuki H, Odaka H, Takita Y, Izumiya Y, Shimizu N. Unusual Manifestation of Dermatomyositis: Exacerbation of Hypertriglyceridemia. Cureus 2023; 15:e51149. [PMID: 38283441 PMCID: PMC10811439 DOI: 10.7759/cureus.51149] [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] [Accepted: 12/26/2023] [Indexed: 01/30/2024] Open
Abstract
Systemic lupus erythematosus is known to cause autoimmune hyperlipidemia. We present a case in which hypertriglyceridemia was exacerbated by dermatomyositis. A 53-year-old woman with a medical history of undertreated hypertriglyceridemia complained of dyspnea and arthralgia. Despite the treatment, her triglyceride levels increased concurrently with the onset of arthralgia. She had characteristic skin manifestations and tested positive for anti-Jo-1 autoantibodies, leading to a diagnosis of dermatomyositis. Chronic inflammation may result in elevated triglyceride levels. When dermatomyositis is diagnosed, evaluating lipid abnormalities is important.
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Affiliation(s)
- Hinako Suzuki
- Post Graduate Clinical Education Center, Japanese Red Cross Akita Hospital, Akita, JPN
| | - Hidesato Odaka
- Department of Respiratory Medicine, Japanese Red Cross Akita Hospital, Akita, JPN
| | - Yuri Takita
- Department of Respiratory Medicine, Japanese Red Cross Akita Hospital, Akita, JPN
| | - Yuka Izumiya
- Department of Respiratory Medicine, Japanese Red Cross Akita Hospital, Akita, JPN
| | - Naoko Shimizu
- Department of Diabetes, Metabolism and Endocrinology, Japanese Red Cross Akita Hospital, Akita, JPN
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9
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Makino H, Kotani T, Hata K, Nishioka D, Yamamoto W, Yoshikawa A, Wada Y, Hiramatsu Y, Shiba H, Nagai K, Katayama M, Son Y, Amuro H, Onishi A, Akashi K, Hara R, Hirano T, Hashimoto M, Takeuchi T. Prognostic factors affecting respiratory-related death in patients with rheumatoid arthritis complicated by interstitial lung disease: An ANSWER cohort study. Mod Rheumatol 2023; 33:928-935. [PMID: 36112486 DOI: 10.1093/mr/roac115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/11/2022] [Accepted: 09/13/2022] [Indexed: 08/27/2023]
Abstract
The aim of this multi-centre retrospective study was to clarify the prognostic factors for respiratory-related death in patients with interstitial lung disease (ILD) complicated rheumatoid arthritis (RA). Patient background data, treatment regimen, and disease activity indicators of RA and ILD at baseline, 6 months after the diagnosis of ILD, and at the last follow-up visit were extracted. A total of 312 patients with RA-ILD (17 patients who died from respiratory-related causes and 295 survivors) were included. Patients who died from respiratory-related causes had an older median age, a higher proportion of being male, and a higher anti-cyclic citrullinated peptide antibody positivity rate than survivors (p = .0001, .038, and .016, respectively); they also had significantly higher baseline serum levels of Krebs von den Lungen-6 (KL-6) than survivors (p = .013). Patients who died from respiratory-related causes showed significantly greater changes in serum KL-6 levels between the 6-month time point and the last visit [ΔKL-6 (6 months - last)] than survivors (p = .011). Multivariate analysis showed that the ΔKL-6 (6 months - last) corrected by disease duration was a predictor of respiratory-disease-related death in patients with RA-ILD (p < .0001). Long-term increase in serum KL-6 levels is associated with respiratory-disease related death in patients with RA-ILD.
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Affiliation(s)
- Hidehiko Makino
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Takuya Kotani
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kenichiro Hata
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Daisuke Nishioka
- Department of Medical Statistics, Research and Development Center, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Wataru Yamamoto
- Department of Health Information Management, Kurashiki Sweet Hospital, Okayama, Japan
| | - Ayaka Yoshikawa
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yumiko Wada
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yuri Hiramatsu
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Hideyuki Shiba
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Koji Nagai
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Masaki Katayama
- Department of Rheumatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yonsu Son
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Hideki Amuro
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Akira Onishi
- Department of Advanced Medicine for Rheumatic diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kengo Akashi
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Ryota Hara
- Rheumatology Clinic and Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Toru Hirano
- Department of Rheumatology, Nishinomiya Municipal Central Hospital, Hyogo, Japan
| | - Motomu Hashimoto
- Department of Clinical Immunology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
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10
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Kim JW, Chung SW, Pyo JY, Chang SH, Kim MU, Park CH, Lee JS, Lee JS, Ha YJ, Kang EH, Lee YA, Park YB, Lee EY, Choe JY. Methotrexate, leflunomide and tacrolimus use and the progression of rheumatoid arthritis-associated interstitial lung disease. Rheumatology (Oxford) 2023; 62:2377-2385. [PMID: 36394143 DOI: 10.1093/rheumatology/keac651] [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: 09/29/2022] [Accepted: 11/08/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE To examine the association between MTX, LEF and tacrolimus use and the progression of RA-associated interstitial lung disease (ILD). METHODS The Korean RA-ILD cohort prospectively enrolled patients with RA-associated ILD at multiple centres from 2015 to 2018 and followed up with them for 3 years. ILD progression was defined by any of the followings: a decrease of ≥10% in forced vital capacity, a decrease of ≥15% in the diffusing capacity of the lung for carbon monoxide, or death from respiratory failure. RESULTS Of 143 patients, 64 patients experienced ILD progression during a median follow-up period of 33 months. The use of MTX [adjusted hazard ratio (aHR), 1.06; 95% CI, 0.59, 1.89], LEF (aHR, 1.75; 95% CI, 0.88, 3.46) and tacrolimus (aHR, 0.94; 95% CI, 0.52, 1.72) did not increase the risk of ILD progression. However, the association between LEF use and the risk of ILD progression was significant in subgroups with poor lung function (aHR, 8.42; 95% CI, 2.61, 27.15). Older age, male sex, a shorter RA duration, higher RA disease activity and extensive disease at baseline were independently associated with ILD progression. CONCLUSION None of the three treatments increased the risk of RA-associated ILD progression, except for LEF, which increased the risk of ILD progression in patients with severe ILD. The appropriate use of conventional synthetic disease-modifying antirheumatic drugs considering RA disease activity and ILD severity would be important for the management of RA-associated ILD.
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Affiliation(s)
- Ji-Won Kim
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Sang Wan Chung
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Jung Yoon Pyo
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hae Chang
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea
| | - Min Uk Kim
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Chan Ho Park
- Department of Radiology, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea
| | - Ji Sung Lee
- Department of Medical Statistics, Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Jeong Seok Lee
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yeon-Ah Lee
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Yoon Choe
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
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11
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Zekić T. Rituximab as the first-line therapy in anti-synthetase syndrome-related interstitial lung disease. Rheumatol Int 2023; 43:1015-1021. [PMID: 36928934 DOI: 10.1007/s00296-023-05302-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
Anti-synthetase syndrome (ASS) is an idiopathic inflammatory myopathy (IIM). In comparison to interstitial lung disease (ILD) in polymyositis and dermatomyositis (PM/DM), ILD in ASS is more frequent, has a more aggressive phenotype, a greater involvement of the lungs, and a more rapid onset of pulmonary symptoms. Continuous declines in predicted forced vital capacity (FVC) and dyspnea were the main features of patients who developed end-stage ILD. The severity of ASS at diagnosis dictates when and which immunosuppressant will be started. There is an experience for the usage of RTX in the first, second, and subsequent lines, as well as for reintroduction and salvage therapies. Not all ASS patients will develop severe illness and require intense immunosuppression. Some features associated with poor prognosis include older age, acute or subacute onset, lack of response to steroids, and lower baseline values for FVC and DLCO. Here we hypothesize that RTX should be the first line of treatment for high-risk ILD in ASS to preserve lung function and then maintenance therapy should be continued with the same or another drug depending on the recovery of lung function.
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Affiliation(s)
- Tatjana Zekić
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Clinical Hospital Center Rijeka, University of Rijeka, Rijeka, Croatia.
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12
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Brazee PL, Knipe RS. Vascular BMPRs Strike Out the Rolling Ball of Fibrosis. Am J Respir Crit Care Med 2023; 207:1419-1421. [PMID: 36952237 PMCID: PMC10263134 DOI: 10.1164/rccm.202303-0382ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Affiliation(s)
- Patricia L Brazee
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
| | - Rachel S Knipe
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
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13
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Thong L, Chawke LJ, Murphy G, Henry MT. "Management of myositis associated interstitial lung disease". Rheumatol Int 2023; 43:1209-1220. [PMID: 37126103 DOI: 10.1007/s00296-023-05336-z] [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: 03/12/2023] [Accepted: 04/22/2023] [Indexed: 05/02/2023]
Abstract
Idiopathic inflammatory myopathies (IIM) are rare disorders characterised by the presence of skeletal muscle inflammation, with interstitial lung disease (ILD) being the most frequent pulmonary manifestation. The spectrum of clinical presentations of myositis related ILD (M-ILD) encompasses a chronic process to a rapidly progressive ILD (RP-ILD); which is associated with a high mortality rate. The most effective treatments remain controversial and poses a unique challenge to both rheumatologists and respiratory physicians to manage. Given the rare heterogenous nature of M-ILD, there is a paucity of data to guide treatment. The cornerstone of existing treatments encompasses combinations of immunosuppressive therapies, as well as non-pharmacological therapies. In this review, we aim to summarize the current pharmacological therapies (including its dosing regimens and side effects profiles) and non-pharmacological therapies. Based on the existing literature to date, we propose a treatment algorithm for both chronic M-ILD and RP-ILD.
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Affiliation(s)
- Lorraine Thong
- Department of Clinical Medicine, Trinity Translational Medical Institute, Trinity College Dublin, St. James Hospital, Dublin, Ireland.
| | - Liam J Chawke
- Department of Clinical Medicine, University Hospital Kerry, Kerry, Ireland
| | - Grainne Murphy
- Department of Rheumatology, Cork University Hospital, Cork, Ireland
| | - Michael T Henry
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
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14
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Liao J, Peng X, Liu J, Xie X, Wang J. The efficacy and safety of tacrolimus in patients with dermatomyositis/polymyositis: A meta-analysis and systematic review. Eur J Intern Med 2023; 110:35-40. [PMID: 36725399 DOI: 10.1016/j.ejim.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/14/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of tacrolimus for dermatomyositis (DM) and polymyositis (PM) treatment. METHODS We searched the Embase, PubMed, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure were used as searching tools from inception up to October 2022. Two authors independently selected studies. The available studies were comprehensively reviewed and investigated. RESULTS A total of 9 studies, including 350 patients, were analysed. Pooled results showed a higher overall survival rate in tacrolimus therapy group. Creatine kinase (CK) levels and forced vital capacity (FVC) showed significant improvement after tacrolimus therapy. The incidence of adverse events including infection and renal dysfunction showed no significant differences between the tacrolimus therapy group and conventional therapy group. CONCLUSION The results of this meta-analysis indicated that GC therapy in combination with tacrolimus therapy could help improving overall survival rate, pulmonary function and had similar safety outcomes compared to conventional therapy in DM and PM patients.
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Affiliation(s)
- Jiafen Liao
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xiaofei Peng
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jiayi Liu
- Xiangya School of Medicine, Central South University, Changsha, Hunan 410011, China
| | - Xi Xie
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jia Wang
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.
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15
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An observational study of clinical recurrence in patients with interstitial lung disease related to the antisynthetase syndrome. Clin Rheumatol 2023; 42:711-720. [PMID: 36334174 DOI: 10.1007/s10067-022-06424-4] [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: 08/01/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe the clinical characteristics and risk factors of clinical recurrence in interstitial lung disease related to antisynthetase syndrome (ARS-ILD). METHODS Patients diagnosed as ARS-ILD in Nanjing Drum Tower Hospital between January 2015 and November 2020 were retrospectively analyzed. Clinical information and treatment course were reviewed. The primary endpoint was the disease recurrence, and the secondary point was mortality. Univariate and multivariable Cox regression analyses were performed to identify risk factors for recurrence. RESULTS Totally, 132 patients with ARS-ILD received immunomodulation treatment from diagnosis. During follow-ups, sixty-nine patients showed recurrence, with a recurrency rate yielding 52.3%. The median duration from treatment initiation to recurrence was 11 (5-18) months. The median tapering course in the recurrence group was 8 (3-12.5) months, which was significantly shorter than the 16 (10-32) months in the no-recurrence group (p < 0.001). Fifty-eight patients experienced recurrence when the glucocorticoids (GC) dose dropped to 10 (9.375-15) mg/day. Twelve patients discontinued GC with a median treatment course of 11.5 (8-16.75) months, and 11 patients developed recurrence after discontinuing GC for 3 (1-4) months. Twelve patients died, with a mortality rate of 9.1%, and recurrence was not associated with increased mortality. The adjusted multivariate analysis showed that age, increased serum lactate dehydrogenase (LDH) level, relatively shorter tapering duration, and inappropriate GC discontinuation were associated with recurrence. CONCLUSION Recurrence of ARS-ILD was common during medication intensity reduction. Age, LDH, medication tapering duration, and discontinuation were risk factors for recurrence. Further efforts to reduce recurrence should take into consideration of these factors. Key Points • Recurrence is observed commonly with a recurrency rate 52.3% in patients with interstitial lung disease related to antisynthetase syndrome (ARS-ILD) when glucocorticoids (GC) tapering or discontinuation. • Age, increased serum lactate dehydrogenase (LDH) level, medication tapering duration, and GC discontinuation were identified to be significantly associated with the recurrence of ARS-ILD.
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16
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Chen Y, Bai Z, Zhang Z, Hu Q, Zhong J, Dong L. The efficacy and safety of tacrolimus on top of glucocorticoids in the management of IIM-ILD: A retrospective and prospective study. Front Immunol 2022; 13:978429. [PMID: 36119045 PMCID: PMC9479328 DOI: 10.3389/fimmu.2022.978429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/16/2022] [Indexed: 12/03/2022] Open
Abstract
Objective To examine the efficacy of tacrolimus on top of glucocorticoids (GCs) in the management of idiopathic inflammatory myopathies-associated interstitial lung disease (IIM-ILD) and further assess the therapeutic benefit and safety of low-dose pirfenidone followed above treatments. Methods The retrospective study comprised 250 patients with IIM-ILD hospitalized in Tongji Hospital from 2014 to 2020. Demographic data, survival outcomes, and recurrence rates over the 1-year follow-up period were retrospectively analyzed. These patients were divided into two groups based on treatment with tacrolimus alone or other conventional immunosuppressants. Endpoints were compared by adjusted Cox regression model using inverse probability of treatment weighting to minimize treatment bias and potential confounders. For the prospective study, IIM-ILD patients treated with tacrolimus alone or tacrolimus combined with low-dose pirfenidone were enrolled from 2018 to 2020. Clinical characteristics, survival outcomes and multifarious assessment scales were followed up at baseline, 3, 6 and 12 months. The primary endpoint was 12-month survival rate and the secondary endpoints included respiratory-related events, adverse events, exacerbation in HRCT findings and laboratory parameters during therapy courses, and changes in respiratory function. Results For the retrospective study, tacrolimus group (n=93) had a significantly higher survival rate (weighted HR=0.330, p=0.002) and a lower relapse rate (weighted HR=0.548, p=0.003) compared with patients treated with other types of immunosuppressant (n=157) after adjustment. The prospectively enrolled 34 IIM-ILD patients were treated with tacrolimus (n=12) or tacrolimus combined with low-dose pirfenidone (n=22). After 12 months of treatment with tacrolimus, patients in the prospective cohort showed significant improvements in cardio-pulmonary function, disease activity, muscle strength, and mental scale from baseline. Subgroup analysis indicated that patients with tacrolimus and pirfenidone combination therapy showed lower chest HRCT scores (p=0.021) and lower respiratory-related relapse rates than those in tacrolimus monotherapy group (log-rank p=0.0029). The incidence rate of drug-associated adverse events (AEs) was comparable between two groups and none of the patients discontinued the treatment due to severe AEs. Conclusion Tacrolimus is well-tolerated and effective in the treatment of IIM-ILD. Furthermore, low-dose pirfenidone add-on treatment seems result in favorable improvements in pulmonary involvements for IIM-ILD patients. Clinical Trial Registration http://www.chictr.org.cn, identifier ChiCTR2100043595.
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Affiliation(s)
- Yuxue Chen
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqian Bai
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziyun Zhang
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiongjie Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Qiongjie Hu, ; Jixin Zhong, ; Lingli Dong,
| | - Jixin Zhong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Qiongjie Hu, ; Jixin Zhong, ; Lingli Dong,
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Qiongjie Hu, ; Jixin Zhong, ; Lingli Dong,
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17
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The Role of Myositis-Specific Autoantibodies and The Management of Interstitial Lung Disease in Idiopathic Inflammatory Myopathies: A Systematic Review. Semin Arthritis Rheum 2022; 57:152088. [DOI: 10.1016/j.semarthrit.2022.152088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 08/21/2022] [Accepted: 08/24/2022] [Indexed: 11/24/2022]
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18
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Kuwana M, Wakasugi N, Furuya T, Uno S, Suda T. Tacrolimus in Patients With Interstitial Pneumonia Associated With Polymyositis or Dermatomyositis: Interim Report of Postmarketing Surveillance in Japan. J Rheumatol 2022; 49:707-718. [PMID: 35428708 DOI: 10.3899/jrheum.210322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The calcineurin inhibitor tacrolimus has been approved in Japan for the treatment of interstitial pneumonia (IP) in patients with polymyositis (PM) and dermatomyositis (DM). Postmarketing surveillance was initiated to examine long-term outcomes of immunosuppressive regimens containing tacrolimus in real-world settings. METHODS Observational, prospective, postmarketing surveillance is ongoing in 179 patients with PM/DM-associated IP initiating treatment with tacrolimus. We report interim findings after 2 years of follow-up. Cumulative overall survival was assessed using Kaplan-Meier analysis. Potential prognostic factors for mortality were assessed by univariate Cox proportional hazards analysis. RESULTS A total of 170 patients were included in this analysis. At the time of starting treatment with tacrolimus, almost all patients were receiving corticosteroids (98.8%), and cyclophosphamide was additionally used in 42 patients (24.7%). Forty-nine patients (28.8%) discontinued tacrolimus during follow-up, mainly due to loss to follow-up, patient death, and adverse events. Mean (SD) oral corticosteroid dose decreased from 32.4 (21.6) mg/day at baseline to 7.6 (4.2) mg/day at 2 years. Overall survival at 2 years was 90.3%; corresponding progression-free survival was 62.5%. Factors found to be associated with all-cause mortality included diagnosis of clinically amyopathic DM (hazard ratio [HR] 9.04, 95% CI 1.18-69.51 vs PM), ferritin level 500 to < 1500 ng/mL (HR 8.61, 95% CI 2.51-29.45 vs < 500 ng/mL), and presence of antimelanoma differentiation-associated gene 5 antibodies (HR 8.16, 95% CI 1.03-64.47 vs absence). CONCLUSION Immunosuppressive regimens containing tacrolimus appear useful for the management of IP in patients with PM/DM. [ClinicalTrials.gov: NCT02159651].
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Affiliation(s)
- Masataka Kuwana
- M. Kuwana, MD, PhD, Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo;
| | - Naoko Wakasugi
- N. Wakasugi, MSc, T. Furuya, MSc, S. Uno, MSc, Astellas Pharma Inc., Tokyo
| | - Toshinori Furuya
- N. Wakasugi, MSc, T. Furuya, MSc, S. Uno, MSc, Astellas Pharma Inc., Tokyo
| | - Satoshi Uno
- N. Wakasugi, MSc, T. Furuya, MSc, S. Uno, MSc, Astellas Pharma Inc., Tokyo
| | - Takafumi Suda
- T. Suda, MD, Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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19
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Dressler F, Maurer B. [Dermatomyositis and juvenile dermatomyositis]. Z Rheumatol 2022; 82:233-245. [PMID: 35486206 DOI: 10.1007/s00393-022-01205-5] [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: 03/17/2022] [Indexed: 11/29/2022]
Abstract
Dermatomyositis (DM) is an inflammatory multisystem disease of unknown etiology, which can already occur in children but first onset can also be in older adulthood. Myalgia and muscle weakness can occur later in the course of the disease or even be completely absent in some forms. Classical signs on the skin include heliotrope rash, facial erythema, Gottron's papules and nailfold capillary abnormalities. For the diagnosis, screening for the presence of myositis-specific autoantibodies has become increasingly more relevant. Muscle enzymes may be elevated but not in approximately one third of patients. In the absence of typical clinical or serologic findings, additional examination methods such as nailfold capillaroscopy, magnetic resonance imaging, electromyography, skin or muscle biopsies may help to establish the diagnosis. Depending on the clinical and serological subtype, additional screening for gastrointestinal or cardiopulmonary involvement should be considered. In adults, an age-appropriate tumor screening should also be performed. Apart from corticosteroids as induction therapy, biologics and small molecule inhibitors are gaining in importance in addition to conventional disease-modifying anti-rheumatic drugs and intravenous immunoglobulins. The prognosis for DM and juvenile DM (JDM) has improved. Most patients recover at least to some extent; however, a few patients die and a minority develop persisting muscle atrophy or severe calcinosis.
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Affiliation(s)
- Frank Dressler
- Kinderklinik, Medizinische Hochschule Hannover, 30623, Hannover, Deutschland.
| | - Britta Maurer
- Universitätsklinik für Rheumatologie und Immunologie, Inselspital Bern, 3010, Bern, Schweiz.
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20
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Shimada T, Higashida-Konishi M, Akiyama M, Hama S, Izumi K, Matsubara S, Oshima H, Okano Y. Immune-mediated necrotizing myopathy which showed deposition of C5b-9 in the necrotic muscle fibers and was successfully treated with intensive combined therapy with high-dose glucocorticoids, tacrolimus, and intravenous immunoglobulins. Immunol Med 2022; 45:175-179. [PMID: 35389818 DOI: 10.1080/25785826.2022.2060169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Currently, no standard treatment strategy has been established for immune-mediated necrotizing myopathy (IMNM). Here we present a case of IMNM which was successfully treated with intensive combined therapy with high-dose glucocorticoids, tacrolimus, and intravenous immunoglobulins. Her muscle weakness was rapidly progressive and severe so that she became bedridden one week after admission. She was complicated with dysphagia and had serum myogenic enzymes elevation, ventricular diastolic dysfunction, and interstitial lung disease. Serum anti-SRP antibody was positive and her muscle biopsy revealed many necrotic fibers with minimal inflammation. Further histological analysis demonstrated infiltration of phagocytic macrophages with deposition of membrane attack complex (C5b-9) in the necrotic muscle fibers, suggesting activation of complement pathway and macrophages as a pathomechanism of this disease. She was diagnosed as IMNM and was immediately initiated a combination therapy described above, which led to dramatic clinical improvements. Recent studies suggest that intravenous immunoglobulins and tacrolimus can inhibit the activation of complement pathway and macrophages. Our present case suggests that early initiation of intensive combined therapy including intravenous immunoglobulins and tacrolimus might be effective for preventing irreversible muscle damages by disrupting a pathogenic activation of complement and macrophages in IMNM.
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Affiliation(s)
- Tatsuya Shimada
- Department of Medicine, Division of Rheumatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Misako Higashida-Konishi
- Department of Medicine, Division of Rheumatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Mitsuhiro Akiyama
- Department of Medicine, Division of Rheumatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Hama
- Department of Medicine, Division of Rheumatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Keisuke Izumi
- Department of Medicine, Division of Rheumatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Shiro Matsubara
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Hisaji Oshima
- Department of Medicine, Division of Rheumatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yutaka Okano
- Department of Medicine, Division of Rheumatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
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21
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Wu Z, Molyneaux PL. Choosing pharmacotherapy for ILD in patients with connective tissue disease. Breathe (Sheff) 2022; 17:210114. [PMID: 35035571 PMCID: PMC8753625 DOI: 10.1183/20734735.0114-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/23/2021] [Indexed: 11/05/2022] Open
Abstract
Interstitial lung disease (ILD) is a well-recognised complication of several connective tissue diseases (CTD). This article outlines the various treatment options for the most common CTD-ILDs and discuss the ongoing research in this field. https://bit.ly/39NHwx6.
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Affiliation(s)
- Zhe Wu
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Philip L Molyneaux
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
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22
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Wang LM, Yang QH, Zhang L, Liu SY, Zhang PP, Zhang X, Liu XJ, Han LS, Li TF. Intravenous immunoglobulin for interstitial lung diseases of anti-melanoma differentiation-associated gene 5-positive dermatomyositis. Rheumatology (Oxford) 2021; 61:3704-3710. [PMID: 34940809 DOI: 10.1093/rheumatology/keab928] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/10/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Rapidly progressive interstitial lung disease (RP-ILD) in dermatomyositis (DM) patients positive for anti-melanoma differentiation-associated gene 5 (anti-MDA5) autoantibody (MDA5-DM) often have poor prognosis, frequently fatal. As there is a scarcity of data regarding the effect of intravenous immunoglobulin (IVIG) on RP-ILD in MDA5-DM patients (MDA5-RPILD), we conducted this study to determine the efficacy of a IVIG add-on initial treatment. METHODS Patients with newly-onset MDA5-RPILD from September 2018 to June 2020 were retrospectively reviewed for 6 months in the First Affiliated Hospital of Zhengzhou University. They were divided into two groups: IVIG and non-IVIG groups. The major measurement of treatment outcome was the difference in the mortality in 3-month and 6-month between two group patients. Other relevant indicators were also recorded, including the incidence of infection, the dosages of GCs, the remission rate and the variables in laboratory data. RESULTS The IVIG group (n = 31) showed significantly lower 6-month mortality rate than the non-IVIG group (n = 17) (22.6% vs 52.9%; p= 0.033). The IVIG group patients had a higher remission rate at 3 months (71.0% vs 41.2%; p= 0.044). Gradual reduction was observed in the first 3 months with regards to the titer of anti-MDA5 autoantibody, the serum level of ferritin, and the GGO scores. CONCLUSION IVIG adjunct therapy is a very effective first-line treatment for patients with MDA5-RPILD. IVIG may increase the survival and remission rate by lowering ferritin concentration, anti-MDA5 titer and GGO score.
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Affiliation(s)
- Li-Mei Wang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qi-Hua Yang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Sheng-Yun Liu
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pan-Pan Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao-Jun Liu
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li-Shuai Han
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tian-Fang Li
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Wilfong EM, Aggarwal R. Role of antifibrotics in the management of idiopathic inflammatory myopathy associated interstitial lung disease. Ther Adv Musculoskelet Dis 2021; 13:1759720X211060907. [PMID: 34917177 PMCID: PMC8669869 DOI: 10.1177/1759720x211060907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/30/2021] [Indexed: 01/13/2023] Open
Abstract
The antifibrotic therapies nintedanib and pirfenidone were first approved by the United States for the treatment of idiopathic pulmonary fibrosis in 2014. In 2020, nintedanib received U.S. Food and Drug Administration (FDA) approval for the treatment of all progressive fibrosing interstitial lung disease (ILD). Given that a major cause of mortality and morbidity in the idiopathic inflammatory myopathies (IIM) is progressive interstitial lung disease and respiratory failure, antifibrotic therapies may be useful as adjuvant to traditional immunosuppression. However, randomized controlled trials of antifibrotic therapies in IIM are lacking. The purpose of this review is to (1) summarize the mechanism of action of nintedanib and pirfenidone in ILD with possible role in IIM-ILD, (2) review the clinical data supporting their use in interstitial lung disease in general, and more specifically in connective tissue disease associated ILD, and (3) discuss the evidence and remaining challenges for using antifibrotic therapies in IIM-ILD.
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Affiliation(s)
- Erin M. Wilfong
- Divisions of Rheumatology and Immunology & Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232 USA
| | - Rohit Aggarwal
- Division of Rheumatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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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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Murata O, Suzuki K, Takeuchi T, Maemondo M. The Risk Factors of Exacerbation in Interstitial Pneumonia With Autoimmune Features: A Single-Center Observational Cohort Study. Rheumatol Ther 2021; 8:1693-1710. [PMID: 34536219 PMCID: PMC8572251 DOI: 10.1007/s40744-021-00371-3] [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: 07/13/2021] [Accepted: 09/02/2021] [Indexed: 12/02/2022] Open
Abstract
Objectives To investigate the long-term outcomes, including risk factors, for exacerbation between monotherapy and combination therapy in patients with interstitial pneumonia with autoimmune features (IPAF). Methods We assessed 672 patients between April 2009 and March 2019 who were evaluated using high-resolution computed tomography (HRCT) of the chest. We applied the IPAF criteria. Fifty-two patients who visited our department for at least 6 months were diagnosed with IPAF. Clinical, laboratory, and imaging data were collected from medical records and statistically analyzed. Results Among the 52 cases of IPAF, we compared the characteristics at diagnosis between treated (n = 28) and untreated patients (n = 24). The exacerbation rates were 42.9% (n = 12) and 8.3% (n = 2) (P = 0.0051), respectively. Among the treated patients, smoking history, high titer of KL-6, and the duration from diagnosis to the start of treatment were significant risk factors for exacerbation (P = 0.0062, 0.011, and 0.019, respectively). The number of risk factors was significantly and positively associated with exacerbation rate (P = 0.0053). Among the treated patients, glucocorticoid (GC) monotherapy was used in 13 cases, and GC and immunosuppressant (IS) combination therapy was used in 14 patients. There was no significant difference in the treatment methods between patients with and without risk factors (P = 0.47). When comparing the long-term outcomes between the monotherapy and combination therapy groups, the 3-year non-exacerbation rates were 72.9 and 45.9% (P = 0.020), respectively. Conclusions IPAF patients with risk factors had a high exacerbation rate, regardless of the type of treatment. New interventions aimed at preventing exacerbations in these patients are required. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00371-3.
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Affiliation(s)
- Okinori Murata
- Division of Pulmonary Medicine, Allergy, and Rheumatology, Department of Internal Medicine, Iwate Medical University School of Medicine, 2-1-1 Idaidori Yahaba-chou Shiwa-gun, Morioka, Iwate, 028-3694, Japan.,Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Maemondo
- Division of Pulmonary Medicine, Allergy, and Rheumatology, Department of Internal Medicine, Iwate Medical University School of Medicine, 2-1-1 Idaidori Yahaba-chou Shiwa-gun, Morioka, Iwate, 028-3694, Japan.
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26
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Kono M, Komai T, Yuki H, Hanata N, Kakumoto T, Kubota A, Maeda MH, Toda T, Shoda H, Fujio K. Anti-Ku Antibody-Positive Myositis Presenting as a Wide Range of Axial Myopathies and Myocarditis: A Case Report and Review of the Literature. Mod Rheumatol Case Rep 2021; 6:64-68. [PMID: 34516654 DOI: 10.1093/mrcr/rxab024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/29/2021] [Accepted: 08/08/2021] [Indexed: 11/14/2022]
Abstract
Idiopathic inflammatory myopathies (IIMs) are autoimmune diseases predominantly affecting proximal muscles; paraspinal muscle involvement is relatively rare. Because paraspinal myopathies do not always cause clinically-evident symptoms, the diagnosis of IIMs with axial myopathies can be challenging. Anti-Ku autoantibodies, initially reported in polymyositis/systemic sclerosis overlap syndrome, are myositis-associated antibodies (MAAs) observed in patients with a wide variety of connective tissue diseases (CTDs). Few reports have been published demonstrating predominant axial myopathy in IIM patients with anti-Ku antibodies. Herein, we investigated a previously healthy Japanese woman in her early 70s who presented with Raynaud's phenomenon, back pain, and exertional dyspnea. The creatine kinase (CK) was elevated and antinuclear antibody staining was positive, but myositis-specific antibodies (MSAs) were negative. Magnetic resonance imaging (MRI) revealed myocarditis and a wide range of axial muscle inflammation, including bilateral thoracolumbar paraspinal, infraspinatus, and trapezius muscles. The muscle biopsy was consistent with IIM. In addition, anti-Ku antibody was positive. Administration of prednisolone and tacrolimus quickly alleviated the symptoms and the CK level returned to normal. The diagnosis of IIM was arduous in this case because she did not present with camptocormia, muscle weakness involving the proximal limbs was not apparent, and MSAs were negative. Whether axial myopathy and myocarditis are more prevalent in IIM patients with than without anti-Ku antibodies is uncertain. Clinicians should suspect axial myopathy and MAAs, such as anti-Ku antibodies, especially in patients in whom muscle weakness of the proximal limbs is not noticeable.
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Affiliation(s)
- Masanori Kono
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshihiko Komai
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hayato Yuki
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norio Hanata
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiyuki Kakumoto
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akatsuki Kubota
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Meiko Hashimoto Maeda
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Shoda
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Anti-tRNA synthetase syndrome interstitial lung disease: A single center experience. Respir Med 2021; 191:106432. [PMID: 33994288 DOI: 10.1016/j.rmed.2021.106432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/10/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recognition of Anti-tRNA synthetase (ARS) related interstitial lung disease (ILD) is key to ensuring patients have prompt access to immunosuppressive therapies. The purpose of this retrospective cohort study was to identify factors that may delay recognition of ARS-ILD. METHODS Patients seen at Vanderbilt University Medical Center between 9/17/2017-10/31/2018 were included in this observational cohort. Clinical and laboratory features were obtained via chart abstraction. Kruskal-Wallis ANOVA, Mann-Whitney U, and Fisher's exact t tests were utilized to determine statistical significance. RESULTS Patients with ARS were found to have ILD in 51.9% of cases, which was comparable to the frequency of ILD in systemic sclerosis (59.5%). The severity of FVC reduction in ARS (53.2%) was comparable to diffuse cutaneous systemic sclerosis (56.8%, p = 0.48) and greater than dermatomyositis (66.9%, p = 0.005) or limited cutaneous systemic sclerosis (71.8%, p = 0.005). Frank honeycombing was seen with ARS antibodies but not other myositis autoantibodies. ARS patients were more likely to first present to a pulmonary provider in a tertiary care setting (53.6%), likely due to fewer extrapulmonary manifestations. Only 33% of ARS-ILD were anti-nuclear antibody, rheumatoid factor, or anti-cyclic citrullinated peptide positive. Patients with ARS-ILD had a two-fold longer median time to diagnosis compared to other myositis-ILD patients (11.0 months, IQR 8.5-43 months vs. 5.0 months, IQR 3.0-9.0 months, p = 0.003). CONCLUSIONS ARS patients without prominent extra-pulmonary manifestations are at high risk for not being recognized as having a connective tissue disease related ILD and miscategorized as usual interstitial pneumonia/idiopathic pulmonary fibrosis without comprehensive serologies.
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Castelino FV, Moua T. Detection and Management of Interstitial Lung Diseases Associated With Connective Tissue Diseases. ACR Open Rheumatol 2021; 3:295-304. [PMID: 33779080 PMCID: PMC8126753 DOI: 10.1002/acr2.11253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/26/2021] [Indexed: 01/08/2023] Open
Abstract
Interstitial lung disease (ILD) is a common manifestation of connective tissue diseases (CTDs). A proportion of patients with CTD-ILDs develop progressive fibrosing ILD, which is characterized by worsening fibrotic abnormalities on high-resolution computed tomography scan, decline in lung function, worsening symptoms, and early mortality. Here, we review the impact of ILD in patients with CTDs, the importance of prompt diagnosis and close monitoring, and the evidence available to guide the management of CTD-ILDs. Management of patients with CTD-ILDs should be individualized and involve close collaboration between rheumatologists and pulmonologists. Immunosuppression is the mainstay of therapy for CTDs, but evidence for its effectiveness in slowing the progression of ILD is limited. Recently, nintedanib has been approved to slow decline in lung function in patients with systemic sclerosis-associated ILD and chronic fibrosing ILDs with a progressive phenotype. The results of ongoing clinical trials will help clinicians take a more evidence-based approach to the treatment of CTD-ILDs.
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29
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Mehta AA, Paul T, Cb M, Haridas N. Anti-MDA5 antibody-positive dermatomyositis with rapidly progressive interstitial lung disease: report of two cases. BMJ Case Rep 2021; 14:14/4/e240046. [PMID: 33910791 PMCID: PMC8094376 DOI: 10.1136/bcr-2020-240046] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Melanoma differentiation-associated protein 5 (MDA5) antibody-positive dermatomyositis (DM) displays unique cutaneous and pathologic features. We describe two cases of myositis-associated rapidly progressive interstitial lung disease (RP-ILD). The patients were two women from Kerala, India. Both patients had anti-MDA5 antibody-positive myositis. Both patients presented with RP-ILD without any clinical features of myositis and succumbed to their illness despite aggressive medical treatment. Anti-MDA5-antibody-positive DM is characterised by amyopathic disease with rapidly progressive and fatal ILD.
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Affiliation(s)
- Asmita A Mehta
- Department of Respiratory Medicine, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Tisa Paul
- Department of Respiratory Medicine, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Mithun Cb
- Rheumatology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Nithya Haridas
- Department of Respiratory Medicine, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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30
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Fujisawa T. Management of Myositis-Associated Interstitial Lung Disease. ACTA ACUST UNITED AC 2021; 57:medicina57040347. [PMID: 33916864 PMCID: PMC8065549 DOI: 10.3390/medicina57040347] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 11/30/2022]
Abstract
Idiopathic inflammatory myopathies, including polymyositis (PM), dermatomyositis (DM), and clinically amyopathic DM (CADM), are a diverse group of autoimmune diseases characterized by muscular involvement and extramuscular manifestations. Interstitial lung disease (ILD) has major pulmonary involvement and is associated with increased mortality in PM/DM/CADM. The management of PM-/DM-/CADM-associated ILD (PM/DM/CADM-ILD) requires careful evaluation of the disease severity and clinical subtype, including the ILD forms (acute/subacute or chronic), because of the substantial heterogeneity of their clinical courses. Recent studies have highlighted the importance of myositis-specific autoantibodies’ status, especially anti-melanoma differentiation-associated gene 5 (MDA5) and anti-aminoacyl tRNA synthetase (ARS) antibodies, in order to evaluate the clinical phenotypes and treatment of choice for PM/DM/CADM-ILD. Because the presence of the anti-MDA5 antibody is a strong predictor of a worse prognosis, combination treatment with glucocorticoids (GCs) and calcineurin inhibitors (CNIs; tacrolimus (TAC) or cyclosporin A (CsA)) is recommended for patients with anti-MDA5 antibody-positive DM/CADM-ILD. Rapidly progressive DM/CADM-ILD with the anti-MDA5 antibody is the most intractable condition, which requires immediate combined immunosuppressive therapy with GCs, CNIs, and intravenous cyclophosphamide. Additional salvage therapies (rituximab, tofacitinib, and plasma exchange) should be considered for patients with refractory ILD. Patients with anti-ARS antibody-positive ILD respond better to GC treatment, but with frequent recurrence; thus, GCs plus immunosuppressants (TAC, CsA, azathioprine, and mycophenolate mofetil) are often needed in order to achieve favorable long-term disease control. PM/DM/CADM-ILD management is still a therapeutic challenge for clinicians, as evidence-based guidelines do not exist to help with management decisions. A few prospective clinical trials have been recently reported regarding the treatment of PM/DM/CADM-ILD. Here, the current knowledge on the pharmacologic managements of PM/DM/CADM-ILD was mainly reviewed.
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Affiliation(s)
- Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama Higashi-ku, Hamamatsu 431-3192, Japan
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Okuno D, Kido T, Muramatsu K, Tokutsu K, Moriyama S, Miyamura T, Hara A, Ishimoto H, Yamaguchi H, Miyazaki T, Sakamoto N, Obase Y, Ishimatsu Y, Fujino Y, Yatera K, Matsuda S, Mukae H. Impact of Corticosteroid Administration within 7 Days of the Hospitalization for Influenza Pneumonia with Respiratory Failure: A Propensity Score Analysis Using a Nationwide Administrative Database. J Clin Med 2021; 10:jcm10030494. [PMID: 33572558 PMCID: PMC7866855 DOI: 10.3390/jcm10030494] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/24/2021] [Accepted: 01/28/2021] [Indexed: 12/15/2022] Open
Abstract
Influenza pneumonia, which causes acute respiratory distress syndrome and multiple organ failure, has no established management protocol. Recently, corticosteroid therapy was used to treat coronavirus disease 2019 with respiratory failure; however, its effectiveness as a treatment for influenza pneumonia remains controversial. To investigate the impact of corticosteroid therapy for the early phase of severe influenza pneumonia, we compared influenza pneumonia patients with respiratory failure treated with or without corticosteroids within 7 days after hospital admission using a Japanese nationwide administrative database. The primary endpoint was the mortality rate. The secondary endpoints were duration of intensive-care unit management, invasive mechanical ventilation, and hospital stay. The inverse probability weighting method with estimated propensity scores was used to minimize the data collection bias. We included 3519 patients with influenza pneumonia with respiratory failure. Of these, 875 were treated with corticosteroids. There was no significant difference between the groups regarding 30-day and 90-day mortality, duration of intensive-care unit management, invasive mechanical ventilation, and hospital stay. However, the in-hospital mortality rate was higher in the corticosteroid group. The use of systematic corticosteroid therapy in patients with influenza pneumonia was associated with a higher in-hospital mortality rate.
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Affiliation(s)
- Daisuke Okuno
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Takashi Kido
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
- Correspondence: ; Tel.: +81-95-819-7273
| | - Keiji Muramatsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan; (K.M.); (K.T.); (S.M.)
| | - Kei Tokutsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan; (K.M.); (K.T.); (S.M.)
| | - Sakiko Moriyama
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Takuto Miyamura
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Atsuko Hara
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Hiroshi Ishimoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Hiroyuki Yamaguchi
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Taiga Miyazaki
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan;
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
| | - Yuji Ishimatsu
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8520, Japan;
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, Institute of Industrial Ecological Science, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan;
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan;
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan; (K.M.); (K.T.); (S.M.)
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (D.O.); (S.M.); (T.M.); (A.H.); (H.I.); (H.Y.); (N.S.); (Y.O.); (H.M.)
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Targeted therapies in interstitial lung disease secondary to systemic autoimmune rheumatic disease. Current status and future development. Autoimmun Rev 2020; 20:102742. [PMID: 33333235 DOI: 10.1016/j.autrev.2020.102742] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/25/2020] [Indexed: 12/22/2022]
Abstract
Autoimmune rheumatic diseases (ARD) are characterized by systemic manifestations and multiple organ involvement, including the lung. Interstitial Lung Disease (ILD) is a cardinal manifestation of lung involvement in patients with ARD and is associated with significant morbidity and mortality. Corticosteroids and immunosuppressive drugs are used as first -line treatment. Targeted therapies, such as biological disease modifying antirheumatic drugs (DMARDS) and anti- fibrotic agents are new treatment options. In this review we discuss the role of targeted therapies in patients with ILD secondary to ARD.
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Fujisawa T, Hozumi H, Kamiya Y, Kaida Y, Akamatsu T, Kusagaya H, Satake Y, Mori K, Mikamo M, Matsuda H, Yokomura K, Koshimizu N, Toyoshima M, Imokawa S, Yasui H, Suzuki Y, Karayama M, Furuhashi K, Enomoto N, Nakamura Y, Inui N, Suda T. Prednisolone and tacrolimus versus prednisolone and cyclosporin A to treat polymyositis/dermatomyositis-associated ILD: A randomized, open-label trial. Respirology 2020; 26:370-377. [PMID: 33179395 DOI: 10.1111/resp.13978] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/28/2020] [Accepted: 10/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE The efficacy of combination therapy with corticosteroids and CNI, TAC and CsA, for PM/DM-ILD has been described retrospectively. However, it remains unknown which CNI treatment regimens, TAC or CsA regimens, are more effective as initial treatments for patients with PM/DM-ILD. METHODS We conducted a prospective multicentre, open-label, randomized, 52-week phase 2 trial. Patients with PM/DM-ILD were randomly allocated to receive PSL plus TAC (TAC group) or PSL plus CsA (CsA group). The primary endpoint was PFS rate in the intention-to-treat population at 52 weeks. The secondary endpoints were OS rate at 52 weeks, changes in pulmonary function tests from baseline to 52 weeks and AE. RESULTS Fifty-eight patients were randomly assigned to the TAC group (n = 30) and the CsA group (n = 28). The PFS rates at 52 weeks were 87% in the TAC group and 71% in the CsA group (P = 0.16). The OS rates at 52 weeks were 97% in the TAC group and 93% in the CsA group (P = 0.50). The %FVC at 52 weeks in the per-protocol populations significantly increased in both groups. None of the patients discontinued the treatment due to AE. CONCLUSION PSL plus TAC treatment may achieve a better short-term PFS rate compared with PSL plus CsA treatment. Further studies must be conducted to evaluate the long-term efficacy and safety of such treatment.
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Affiliation(s)
- Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hironao Hozumi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yosuke Kamiya
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yusuke Kaida
- Department of Respiratory Medicine, Enshu Hospital, Hamamatsu, Japan
| | - Taisuke Akamatsu
- Department of Respiratory Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Hideki Kusagaya
- Department of Respiratory Medicine, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Yasuomi Satake
- Department of Respiratory Medicine, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Kazutaka Mori
- Department of Respiratory Medicine, Shizuoka City Shimizu Hospital, Shizuoka, Japan
| | - Masashi Mikamo
- Department of Respiratory Medicine, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Hiroyuki Matsuda
- Department of Respiratory Medicine, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Koshi Yokomura
- Department of Respiratory Medicine, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naoki Koshimizu
- Department of Respiratory Medicine, Fujieda Municipal General Hospital, Fujieda, Japan
| | - Mikio Toyoshima
- Department of Respiratory Medicine, Hamamatsu Rosai Hospital, Hamamatsu, Japan
| | - Shiro Imokawa
- Department of Respiratory Medicine, Iwata City Hospital, Iwata, Japan
| | - Hideki Yasui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuzo Suzuki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masato Karayama
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kazuki Furuhashi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Inui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Huang K, Aggarwal R. Antisynthetase syndrome: A distinct disease spectrum. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2020; 5:178-191. [PMID: 35382516 PMCID: PMC8922626 DOI: 10.1177/2397198320902667] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/11/2019] [Indexed: 07/28/2023]
Abstract
The discovery of novel autoantibodies related to idiopathic inflammatory myopathies (collectively referred to as myositis) has not only advanced our understanding of the clinical, serological, and pathological correlation in the disease spectrum but also played a role in guiding management and prognosis. One group of the myositis-specific autoantibodies is anti-aminoacyl-tRNA synthetase (anti-ARS or anti-synthetase) which defines a syndrome with predominant interstitial lung disease, arthritis, and myositis. Autoantibodies to eight aminoacyl-tRNA synthetases have been identified with anti-Jo1 the most common in all of idiopathic inflammatory myopathies. Disease presentation and prognosis vary depending on which anti-aminoacyl-tRNA synthetase antibody is present. In this review, we will discuss the clinical characteristics, overlap features with other autoimmune diseases, prognostic factors, and management of the antisynthetase syndrome.
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Affiliation(s)
- Kun Huang
- Division of Rheumatology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Rohit Aggarwal
- Arthritis and Autoimmunity Center and UPMC Myositis Center, Division of Rheumatology and Clinical Immunology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Takada K, Katada Y, Ito S, Hayashi T, Kishi J, Itoh K, Yamashita H, Hirakata M, Kawahata K, Kawakami A, Watanabe N, Atsumi T, Takasaki Y, Miyasaka N. Impact of adding tacrolimus to initial treatment of interstitial pneumonitis in polymyositis/dermatomyositis: a single-arm clinical trial. Rheumatology (Oxford) 2020; 59:1084-1093. [PMID: 31539061 PMCID: PMC7850120 DOI: 10.1093/rheumatology/kez394] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/19/2019] [Indexed: 12/19/2022] Open
Abstract
Objective Interstitial pneumonia is common and has high short-term mortality in patients with PM and DM despite glucocorticoid (GC) treatment. Retrospective studies suggested that the early use of immunosuppressive drugs with GCs might improve its short-term mortality. Methods A multicentre, single-arm, 52-week-long clinical trial was performed to test whether the initial combination treatment with tacrolimus (0.075 mg/kg/day, adjusted for the target whole-blood trough levels between 5 and 10 ng/ml) and GCs (0.6–1.0 mg/kg/day of prednisolone followed by a slow taper) improves short-term mortality of PM/DM-interstitial pneumonia patients. The primary outcome was overall survival. We originally intended to compare, by using propensity-score matching, the outcome data of clinical trial patients with that of historical control patients who were initially treated with GCs alone. Results The 52-week survival rate with the combination treatment (N = 26) was 88.0% (95% CI, 67.3, 96.0). Safety profiles of the combination treatment were consistent with those known for tacrolimus and high-dose GCs individually. Serious adverse events occurred in 11 patients (44.0%), which included four opportunistic infections. Only 16 patients, including only 1 deceased patient, were registered as historical controls, which precluded meaningful comparative analysis against the clinical trial patients. Conclusion Our study provided findings which suggest that initial treatment with tacrolimus and GCs may improve short-term mortality of PM/DM-interstitial pneumonia patients with manageable safety profiles. This was the first prospective clinical investigation conducted according to the Good Clinical Practice Guideline of the International Conference on Harmonization for the treatment of this potentially life-threatening disease. Trial registration ClinicalTrials.gov, http://clinicaltrials.gov, NCT00504348.
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Affiliation(s)
- Kazuki Takada
- Department of Professional Development in Health Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Yoshinori Katada
- Department of Rheumatology and Clinical Immunology, Sakai City Medical Center, Osaka
| | - Satoshi Ito
- Department of Rheumatology, Niigata Rheumatic Center, Niigata
| | - Taichi Hayashi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Jun Kishi
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima
| | - Kenji Itoh
- Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, Saitama
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo
| | - Michito Hirakata
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo
| | - Kimito Kawahata
- Division of Rheumatology and Allergology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Norihiko Watanabe
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Hokkaido
| | - Yoshinari Takasaki
- Department of Internal Medicine, Juntendo University Koshigaya Hospital, Saitama
| | - Nobuyuki Miyasaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Insights into pathogenesis and clinical implications in myositis-associated interstitial lung diseases. Curr Opin Pulm Med 2020; 26:507-517. [PMID: 32657836 DOI: 10.1097/mcp.0000000000000698] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Interstitial lung diseases (ILDs) have been reported to be associated with myositis (including polymyositis and dermatomyositis). These myositis-associated ILDs carry significant morbidity and mortality. This review summarizes recent findings on myositis-associated ILD with a focus on pathogenesis and emerging treatment. RECENT FINDINGS Recent advances in genetics have revealed 22 myositis-associated genome-wide loci, which were significantly enriched in regulatory regions in immune cells. An analysis of such disease-associated loci elucidated potential drug targets (e.g., TYK2 targeted by tofacitinib). In another study, an intronic variant in WDFY4 in association with clinically amyopathic dermatomyositis (CADM) had an effect for higher expression of a truncated WDFY4 isoform. Truncated WDFY4 markedly enhanced the MDA5-mediated NF-κB activation and cell apoptosis, indicating the dysregulated WDFY4-MDA5 pathway as a novel pathogenesis of CADM. As a novel strategy, tofacitinib treatment showed a promising improvement in survival and clinical features of CADM-associated ILD. SUMMARY The genetic differences in the myositis-susceptible loci may explain the heterogeneous phenotypes and treatment responses in myositis-associated ILD. The understanding of pathogenesis with the genetic background as well as autoantibodies will enable the practice of personalized treatment in the management of the disease.
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Abstract
The idiopathic inflammatory myopathies (IIMs), including polymyositis (PM) and dermatomyositis (DM), are autoimmune connective tissue diseases with variable degrees of muscle inflammation and systemic involvement. Interstitial lung disease (ILD) is a common complication of the IIMs and is associated with increased mortality. Many patients with PM/DM have myositis-specific and myositis-associated antibodies (MSA/MAAs) that result in distinct clinical phenotypes. Among these MSAs, anti-aminoacyl-tRNA antibodies and anti-melanoma differentiation factor 5 antibodies have high rates of ILD. Corticosteroids are the mainstay of treatment, although the addition of other immunosuppressive therapy is typically necessary to achieve disease control.
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Takei R, Yamano Y, Kataoka K, Yokoyama T, Matsuda T, Kimura T, Johkoh T, Takahashi O, Kondoh Y. Predictive factors for the recurrence of anti-aminoacyl-tRNA synthetase antibody-associated interstitial lung disease. Respir Investig 2020; 58:83-90. [PMID: 31813784 DOI: 10.1016/j.resinv.2019.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Anti-synthetase syndrome (ASS) is characterized by the presence of anti-aminoacyl-tRNA synthetase antibody and ASS-associated interstitial lung disease (ILD) often recurs. The effectiveness of remission induction therapy with corticosteroids and calcineurin inhibitor (CNI) and the predictive factors for ASS-ILD recurrence were examined. METHODS We retrospectively identified consecutive patients with ASS-ILD treated with corticosteroids and CNI during 2006-2017 and evaluated the predictive factors for recurrence using logistic regression analysis. RESULTS Of the 57 patients included in this study, 54 (94.7%) exhibited improved response to remission induction therapy. There were 32 recurrence patients during maintenance therapy. The median period until recurrence was 27 months. There were no significant differences in the baseline characteristics between the recurrence and nonrecurrence groups. In the recurrence group, respiratory function and St. George's Respiratory Questionnaire score deteriorated over the clinical course. The Krebs von den Lungen-6 (KL-6) level changed with disease behavior. The multivariate analysis revealed that KL-6 increase rate from remission (odds ratio: 3.21, 95% CI: 1.17-8.86, p = 0.02) and CNI discontinuation (odds ratio: 8.09, 95% CI: 1.39-47.09, p = 0.02) were independent predictive factors for recurrence. The receiver operating characteristics analysis revealed that the optimal cut-off point of KL-6 increase rate was 2.0. The positive predictive values of the KL-6 increase rate from remission of >2.0 and CNI discontinuation were 90.0 and 88.9%, respectively. The CNI treatment duration and recurrence were not related. CONCLUSIONS Recurrence influenced long-term deterioration. KL-6 was a serum biomarker for disease behavior and recurrence prediction. The results suggest the importance of CNI continuation.
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Affiliation(s)
- Reoto Takei
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Toshiki Yokoyama
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Toshiaki Matsuda
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Tomoki Kimura
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kinki Central Hospital of Mutual Aid Association of Public Health Teachers, Itami, Japan
| | - Osamu Takahashi
- Division of Clinical Epidemiology, Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan.
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Broen JCA, van Laar JM. Mycophenolate mofetil, azathioprine and tacrolimus: mechanisms in rheumatology. Nat Rev Rheumatol 2020; 16:167-178. [PMID: 32055040 DOI: 10.1038/s41584-020-0374-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 02/08/2023]
Abstract
The introduction of biologic DMARDs into rheumatology has resulted in a substantial reduction of the burden of many rheumatic diseases. In the slipstream of the success achieved with these biologic DMARDs, some conventional immunosuppressive drugs have also found use in new indications. Notably, mycophenolate mofetil, azathioprine and tacrolimus have made their way from solid organ transplantation drugs to become useful assets in rheumatology practice. Mycophenolate mofetil and azathioprine inhibit the purine pathway and subsequently diminish cell proliferation. Both drugs have a pivotal role in the treatment of various rheumatic diseases, including lupus nephritis. Tacrolimus inhibits lymphocyte activation by inhibiting the calcineurin pathway. Mycophenolate mofetil and tacrolimus are, among other indications, increasingly being recognized as useful drugs in the treatment of interstitial lung disease in systemic rheumatic diseases and skin fibrosis in systemic sclerosis. A broad array of trials with mycophenolate mofetil, azathioprine and/or tacrolimus are ongoing within the field of rheumatology that might provide further novel avenues for the use of these drugs. In this Review, we discuss the historical perspective, pharmacodynamics, clinical indications and novel avenues for mycophenolate mofetil, azathioprine and tacrolimus in rheumatology.
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Affiliation(s)
- Jasper C A Broen
- Regional Rheumatology Center, Máxima Medical Center, Eindhoven and Veldhoven, Eindhoven, the Netherlands
| | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Jablonski R, Bhorade S, Strek ME, Dematte J. Recognition and Management of Myositis-Associated Rapidly Progressive Interstitial Lung Disease. Chest 2020; 158:252-263. [PMID: 32059958 DOI: 10.1016/j.chest.2020.01.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 01/07/2020] [Accepted: 01/22/2020] [Indexed: 01/30/2023] Open
Abstract
Idiopathic inflammatory myopathies are autoimmune processes that are characterized by skeletal muscle inflammation. The lung is the most commonly involved extramuscular organ, and, when present, pulmonary disease drives morbidity and mortality. A subset of patients can present with rapidly progressive hypoxemic respiratory failure due to myositis-related interstitial lung disease. Confirmatory autoantibody testing requires sending samples to a reference laboratory; thus, diagnosis of rapidly progressive myositis-associated interstitial lung disease relies on a high index of suspicion and careful history and physical examination. Although the cornerstone of therapy for these patients remains multimodality immunosuppression, emerging data support a role for advanced therapies (including extracorporeal membrane oxygenation and lung transplantation) in appropriately selected patients. It is hoped that greater awareness of the clinical features of this syndrome will allow for appropriate diagnosis and treatment of these potentially treatable patients, as well as raise awareness of the need for multicenter collaboration to prospectively study how to manage this complex disease.
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Affiliation(s)
- Renea Jablonski
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
| | - Sangeeta Bhorade
- Veracyte, San Francisco, CA; Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mary E Strek
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Jane Dematte
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL
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Current and Emerging Drug Therapies for Connective Tissue Disease-Interstitial Lung Disease (CTD-ILD). Drugs 2020; 79:1511-1528. [PMID: 31399860 DOI: 10.1007/s40265-019-01178-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Interstitial lung disease (ILD) can be associated with all connective tissue diseases and is an important cause of morbidity and mortality. The management of connective tissue disease-interstitial lung disease (CTD-ILD) is challenging due substantial heterogeneity in disease behaviour and paucity of controlled clinical trials to guide treating clinicians. Not all patients require treatment, and the decision to treat needs to be individualised based on a patient's observed disease behaviour, baseline and longitudinal lung function measurements, extent of lung involvement on radiology and patient factors including age, co-morbidities and personal preference. If indicated, treatment of the CTD-ILD is largely with immunomodulation, with the aim to prevent progression of the ILD before further irreversible lung injury and disability occurs. Corticosteroids, cyclophosphamide, mycophenolate mofetil and azathioprine are the most common immunosuppressive agents currently used to treat CTD-ILD, demonstrating stability of lung function in case series and a small number of randomised controlled trials in ILD associated with systemic sclerosis. Biological and non-biological disease-modifying anti-rheumatic drugs, and the anti-fibrotics nintedanib and pirfenidone, have revolutionised the treatment of connective tissue diseases and idiopathic ILD, respectively. Furthermore, anti-fibrotics have recently demonstrated safety and efficacy in ILD associated with systemic sclerosis. There remains a critical unmet need to clarify when and in whom to initiate treatment, and which agent(s) to utilise to achieve optimal outcomes for CTD-ILD patients whilst minimising harms through prospective multicentre trials. This review highlights the challenges faced when treating patients with CTD-ILD and summarises available evidence for current, emerging and novel therapies.
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Vacchi C, Sebastiani M, Cassone G, Cerri S, Della Casa G, Salvarani C, Manfredi A. Therapeutic Options for the Treatment of Interstitial Lung Disease Related to Connective Tissue Diseases. A Narrative Review. J Clin Med 2020; 9:jcm9020407. [PMID: 32028635 PMCID: PMC7073957 DOI: 10.3390/jcm9020407] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 12/13/2022] Open
Abstract
Interstitial lung disease (ILD) is one of the most serious pulmonary complications of connective tissue diseases (CTDs) and it is characterized by a deep impact on morbidity and mortality. Due to the poor knowledge of CTD-ILD’s natural history and due to the difficulties related to design of randomized control trials, there is a lack of prospective data about the prevalence, follow-up, and therapeutic efficacy. For these reasons, the choice of therapy for CTD-ILD is currently very challenging and still largely based on experts’ opinion. Treatment is often based on steroids and conventional immunosuppressive drugs, but the recent publication of the encouraging results of the INBUILD trial has highlighted a possible effective and safe use of antifibrotic drugs as a new therapeutic option for these subjects. Aim of this review is to summarize the available data and recent advances about therapeutic strategies for ILD in the context of various CTD, such as systemic sclerosis, idiopathic inflammatory myopathy and Sjogren syndrome, systemic lupus erythematosus, mixed connective tissue disease and undifferentiated connective tissue disease, and interstitial pneumonia with autoimmune features, focusing also on ongoing clinical trials.
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Affiliation(s)
- Caterina Vacchi
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Giulia Cassone
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Stefania Cerri
- Respiratory Disease Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Giovanni Della Casa
- Radiology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Carlo Salvarani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Andreina Manfredi
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
- Correspondence:
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Kobayashi I, Akioka S, Kobayashi N, Iwata N, Takezaki S, Nakaseko H, Sato S, Nishida Y, Nozawa T, Yamasaki Y, Yamazaki K, Arai S, Nishino I, Mori M. Clinical practice guidance for juvenile dermatomyositis (JDM) 2018-Update. Mod Rheumatol 2020; 30:411-423. [PMID: 31955618 DOI: 10.1080/14397595.2020.1718866] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Juvenile dermatomyositis is the most common type of juvenile idiopathic inflammatory myopathy mainly affecting the skin and proximal muscles. We have published the Japanese version of 'Clinical practice guidance for juvenile dermatomyositis (JDM) 2018 'consisting of a review of articles in the field and evidence-informed consensus-based experts' opinion on the treatment strategy in collaboration with The Pediatric Rheumatology Association of Japan and The Japan College of Rheumatology under the financial support by 'Research on rare and intractable diseases, Health and Labor Sciences Research Grants'. This article is a digest version of the Japanese guidance.
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Affiliation(s)
- Ichiro Kobayashi
- Center for Pediatric Allergy and Rheumatology, KKR Sapporo Medical Center, Sapporo, Japan
| | - Shinji Akioka
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Norimoto Kobayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | | | - Haruna Nakaseko
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | - Satoshi Sato
- Division of Infectious Disease and Immunology, Saitama Children's Medical Center, Omiya, Japan
| | - Yutaka Nishida
- Department of Pediatrics, School of Medicine, Gunma University, Maebashi, Japan
| | - Tomo Nozawa
- Department of Pediatrics, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yuichi Yamasaki
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Kazuko Yamazaki
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Satoru Arai
- Department of Dermatology, St. Luke's International Hospital, Tokyo, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masaaki Mori
- Lifetime Clinical Immunology, Tokyo Medical and Dental University, Tokyo, Japan
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Hervier B, Uzunhan Y. Inflammatory Myopathy-Related Interstitial Lung Disease: From Pathophysiology to Treatment. Front Med (Lausanne) 2020; 6:326. [PMID: 32010700 PMCID: PMC6978912 DOI: 10.3389/fmed.2019.00326] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/19/2019] [Indexed: 12/13/2022] Open
Abstract
Inflammatory myopathies (IM) are auto-immune connective tissue diseases characterized by muscle involvement and by extramuscular manifestations. As such, pulmonary manifestations, which mainly include interstitial lung disease (ILD), often darken two out of four distinct IM, namely dermatomyositis and overlapping myositis. Being the initiation site of the disease and being the leading cause of morbidity and mortality, ILD is of major importance in this context. ILD has a heterogeneous expression among the patients, with various onset mode, various radiological pattern, various severity and finally with different prognoses, which are particularly difficult to predict at the time of IM diagnosis. Therefore, ILD is a challenging issue. Treatments are based on steroids and immunosuppressive or targeted therapies. Their respective place is yet poorly codified however and remains often based on clinician expertise. Dedicated clinical trials are lacking to date and are also difficult to build, due to difficulty of constituting large and homogeneous patient groups and to rigorously evaluate disease outcomes. Indeed, pulmonary function tests alone are being regularly defeated in IM, in which respiratory muscles are often involved. Composite scores, bringing together several lung parameters, should thus be developed and validated in the future, to better assess the disease response to treatment. This review aims to describe the current knowledge of IM immuno-pathogenesis, the clinical features associated with IM related-ILD, focusing of both severity and prognosis, and the actual therapeutic approaches.
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Affiliation(s)
- Baptiste Hervier
- Internal Medicine and Clinical Immunology Department, French Referral Centre for Rare Neuromuscular Disorders, Hôpital Pitié-Salpêtrière, APHP, Paris, France.,INSERM UMR-S 1135, CIMI-Paris, UPMC & Sorbonne Université, Paris, France
| | - Yurdagül Uzunhan
- Pneumology Department, Reference Center for Rare Pulmonary Diseases, Hôpital Avicenne, APHP, Bobigny, France.,INSERM UMR1272, Université Paris 13, Bobigny, France
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Abstract
PURPOSE OF THE REVIEW Dermatomyositis (DM) is an uncommon autoimmune disease that primarily affects the skin, muscle, and/or lungs, and remains a therapeutic challenge. We discuss recent studies evaluating efficacy of conventional treatments for clinically amyopathic DM (CADM), DM-associated interstitial lung (ILD) disease, and classic DM (CDM). We highlight several emerging new therapies with a focus on clinical trials, systematic reviews, and case series in the last 5 years. RECENT FINDINGS Recent studies report a significant number of patients remain refractory to antimalarials and require second- and third-line agents. Effective treatment for DM-associated ILD can vary based on patient specific antibodies. CDM requires oral glucocorticoids; recent studies have evaluated the benefits of adjunctive therapies including methotrexate and calcineurin inhibitors. New therapies target cell populations or cytokines thought to drive disease pathogenesis. Dermatomyositis is an autoimmune disease that remains challenging to treat. Many patients are refractory to conventional therapies, warranting the development and evaluation of new treatments.
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Suda K, Yamashita T, Kawase Y, Yarita K, Yoshizaki A, Akamata K, Asano Y, Kamei K, Sato S. Cutaneous phaeohyphomycosis caused by Alternaria alternata in an immunosuppressed patient. J Dermatol 2019; 46:e448-e449. [PMID: 31432527 DOI: 10.1111/1346-8138.15041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kumiko Suda
- Department of Dermatology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Takashi Yamashita
- Department of Dermatology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Yuriko Kawase
- Department of Dermatology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Kyoko Yarita
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Asako Yoshizaki
- Department of Dermatology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Kaname Akamata
- Department of Dermatology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Yoshihide Asano
- Department of Dermatology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Katsuhiko Kamei
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Shinichi Sato
- Department of Dermatology, The University of Tokyo School of Medicine, Tokyo, Japan
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Horiike Y, Suzuki Y, Fujisawa T, Yasui H, Karayama M, Hozumi H, Furuhashi K, Enomoto N, Nakamura Y, Inui N, Ogawa N, Suda T. Successful classification of macrophage-mannose receptor CD206 in severity of anti-MDA5 antibody positive dermatomyositis associated ILD. Rheumatology (Oxford) 2019; 58:2143-2152. [DOI: 10.1093/rheumatology/kez185] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/08/2019] [Indexed: 12/30/2022] Open
Abstract
Abstract
Objectives
Macrophage-mannose receptor, CD206, is a marker of alternatively activated macrophages. Activated macrophages play key roles in DM. Interstitial lung disease (ILD) is a leading cause of mortality in patients with DM/clinically amyopathic DM (CADM). In particular, patients with the anti-melanoma differential gene 5 antibody (MDA5) frequently develop fatal rapid progressive ILD. This study aimed to evaluate the clinical implications of alternatively activated macrophages in patients with CADM/DM-ILD with anti-MDA5 antibody (MDA5-CADM/DM-ILD).
Methods
We measured serum concentrations of soluble CD206 (sCD206) in 33 patients with MDA5-CADM/DM-ILD and 36 age- and sex-matched control subjects. Expression levels of CD206 in the lungs from MDA5-CADM/DM-ILD were also examined.
Results
Patients with MDA5-CADM/DM-ILD had higher levels of sCD206 than those in controls (P < 0.0001). Of the 33 patients, 10 MDA5-CADM/DM-ILD patients developed fatal respiratory failure. Concentrations of sCD206 in patients with fatal ILD cases were significantly higher than those in the survivors, and increased sCD206 levels were associated with a higher mortality rate (Log-rank test, P = 0.0009). Age- and gender-adjusted logistic regression analyses showed that sCD206 was an independent prognostic factor for MDA5-CADM/DM-ILD. Importantly, assessment by sCD206 together with PaO2 successfully divided into three groups by their prognosis (P < 0.005, respectively). Pathological analyses showed accumulations of CD206-positive macrophages in lungs from the fatal case rather than those in the non-fatal cases.
Conclusions
Levels of serum sCD206 are increased in MDA5-CADM/DM-ILD and associated with poor prognosis. sCD206 is a potential biomarker to predict the severity of MDA5-CADM/DM-ILD.
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Affiliation(s)
- Yasuoki Horiike
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Yuzo Suzuki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Hideki Yasui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Masato Karayama
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Hironao Hozumi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Kazuki Furuhashi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Naoki Inui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Noriyoshi Ogawa
- Third Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu,Japan
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Shappley C, Paik JJ, Saketkoo LA. Myositis-Related Interstitial Lung Diseases: Diagnostic Features, Treatment, and Complications. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019; 5:56-83. [PMID: 31984206 DOI: 10.1007/s40674-018-0110-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Courtney Shappley
- Ochsner Advanced Lung Disease Program, Ochsner Hospital Foundation, New Orleans, LA
- Tulane University Section of Pulmonary Medicine and Critical Care, New Orleans, LA
| | - Julie J Paik
- Johns Hopkins Medical Institute, Myositis Program, Baltimore, MD
| | - Lesley Ann Saketkoo
- Tulane University Section of Pulmonary Medicine and Critical Care, New Orleans, LA
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center
- University Medical Center Comprehensive Pulmonary Hypertension Center
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Iudici M, Porcher R, Riveros C, Ravaud P. Time-dependent biases in observational studies of comparative effectiveness research in rheumatology. A methodological review. Ann Rheum Dis 2019; 78:562-569. [DOI: 10.1136/annrheumdis-2018-214544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/02/2019] [Accepted: 01/23/2019] [Indexed: 01/10/2023]
Abstract
ObjectiveTo assess to what extent time-dependent biases (ie, immortal time bias (ITB) and time-lag bias (TLB)) occur in the latest rheumatology observational studies, describe their main mechanisms and increase the awareness on this topic.MethodsWe searched PubMed for observational studies on rheumatic diseases published in leading medical journals in the last 5 years. Only studies with a time-to-event analysis exploring the association of one or more interventional strategies with an outcome were included. Each study was labelled as free from bias, at risk of TLB, at risk of misclassified ITB if the period of immortal time was incorrectly attributed to an intervention group, or at risk of excluded ITB if the immortal time was discarded from the analysis.ResultsWe included 78 papers. Most studies were performed in Europe or North America (46% each), were not industry funded (62%) and had a safety primary outcome (59%). In total, 13 (17%) studies were considered at risk of time-dependent biases. Among the studies at risk of ITB (n=8; 10%), in 5 (6%), waiting time to receive treatment was wrongly attributed to the treatment exposure group, which indicated misclassified ITB. Five (6%) studies were at risk of TLB: patients on conventional synthetic disease-modifying antirheumatic drugs (DMARD; first-line drugs) were compared with patients on biologic DMARDs (second or third-line drugs) without accounting for disease duration or prior medication use.ConclusionsOne in six comparative effectiveness observational studies published in leading rheumatology journals is potentially flawed by time-dependent biases.
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Hozumi H, Fujisawa T, Nakashima R, Yasui H, Suzuki Y, Kono M, Karayama M, Furuhashi K, Enomoto N, Inui N, Nakamura Y, Mimori T, Suda T. Efficacy of Glucocorticoids and Calcineurin Inhibitors for Anti-aminoacyl-tRNA Synthetase Antibody–positive Polymyositis/dermatomyositis–associated Interstitial Lung Disease: A Propensity Score–matched Analysis. J Rheumatol 2019; 46:509-517. [DOI: 10.3899/jrheum.180778] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2018] [Indexed: 12/15/2022]
Abstract
Objective.The optimal treatment strategy for anti-aminoacyl-tRNA synthetase antibody–positive polymyositis/dermatomyositis-associated interstitial lung disease (anti-ARS-PM/DM-ILD) is yet to be established. We aimed to evaluate the efficacy of glucocorticoids and calcineurin inhibitors (CNI) in patients with ARS-PM/DM-ILD.Methods.Progression-free survival (PFS) and overall survival rates were retrospectively evaluated in 32 consecutive patients with ARS-PM/DM-ILD. Disease progression was defined as deterioration in PM/DM-ILD (including recurrence). Predictive factors associated with PFS were analyzed by Cox hazards analysis. The efficacy of first-line prednisolone (PSL) plus CNI therapy was compared with that of PSL monotherapy using propensity score–matched analysis.Results.Overall, 20 (62.5%) and 12 (37.5%) patients received first-line therapy with PSL + CNI and PSL, respectively. The 2-year PFS and 5-year survival rates in the overall cohort were 68.8% and 96.9%, respectively. On multivariate analysis, arterial oxygen pressure (HR 0.86) and PSL monotherapy (vs PSL + CNI; HR 7.29) showed an independent association with PFS. Baseline characteristics of propensity score-matched PSL + CNI and PSL groups were similar. The 2-year PFS rate was significantly higher in the matched PSL + CNI group than in the matched PSL group. All patients who experienced disease progression during first-line therapy were subsequently treated with second-line therapies. The 5-year survival rates of both the matched PSL + CNI and PSL groups were favorable.Conclusion.Propensity score–matched analysis demonstrated that first-line PSL + CNI therapy for patients with ARS-PM/DM-ILD significantly improved the PFS compared with PSL monotherapy, although there was no significant difference regarding longterm survival.
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