Cyclosporine treatment for polymyositis/dermatomyositis: is it possible to rescue the deteriorating cases with interstitial pneumonitis?

Lipid-lowering Therapies in Myositis

PURPOSE OF REVIEW

The use of lipid-lowering therapies in patients with idiopathic inflammatory myopathies (IIM) is complicated and there are no guidelines for diagnosing, monitoring, or treating atherosclerotic cardiovascular disease (ASCVD) in this group of patients.

RECENT FINDINGS

The use of lipid-lowering therapies, especially statins, is recommended in patients with increased risk for ASCVD, which includes patients with inflammatory diseases, based on recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines for ASCVD management. There is accumulating evidence that patients with IIM are at increased risk for ASCVD, similar to other inflammatory diseases. Lipid-lowering therapies have side effects that may be pronounced or confounding in myositis patients, potentially limiting their use. Statins are specifically contraindicated in patients with anti 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) antibodies. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to be safe and potentially beneficial in patients with IIM. Here, we propose a framework for (1) ASCVD risk assessment and treatment based on ACC/AHA ASCVD primary prevention guidelines; (2) myositis disease monitoring while undergoing lipid-lowering therapy; and (3) management of statin intolerance, including, indications for the use of PCSK9 inhibitors.

Treatment of inflammatory myopathies

INTRODUCTION

The idiopathic inflammatory myopathies (IIM) dermatomyositis (DM) and polymyositis (PM) are chronic diseases affecting the striated muscles with variable involvement of other organs. Glucocorticoids are considered the cornerstone of treatment, but some patients require adjunctive immunosuppressive agents because of insufficient response to glucocorticoids, flares upon glucocorticoid tapering, or glucocorticoid-related adverse events. Areas covered: The aim of this article was to review (PubMed search until February 2018) the evidence on established and new therapies derived from randomized controlled trials (RCTs) on adult DM and PM. In addition, key data from open-label trials, case reports, and abstracts were included where data from RCT were lacking. Expert commentary: Numerous synthetic and biological immunosuppressive agents are currently available to treat the IIM, sometimes in combination. The choice of the specific medication in the individual patient depends upon the disease phenotype and patient's characteristics. Exercise improves muscle performance without causing disease flares and should be an integral part of the treatment of the IIM. Prompt diagnosis and treatment can lead to better outcome.

Idiopathic Inflammatory Myopathies: Clinical Approach and Management

Idiopathic inflammatory myopathies (IIM) are a group of chronic, autoimmune conditions affecting primarily the proximal muscles. The most common types are dermatomyositis (DM), polymyositis (PM), necrotizing autoimmune myopathy (NAM), and sporadic inclusion body myositis (sIBM). Patients typically present with sub-acute to chronic onset of proximal weakness manifested by difficulty with rising from a chair, climbing stairs, lifting objects, and combing hair. They are uniquely identified by their clinical presentation consisting of muscular and extramuscular manifestations. Laboratory investigations, including increased serum creatine kinase (CK) and myositis specific antibodies (MSA) may help in differentiating clinical phenotype and to confirm the diagnosis. However, muscle biopsy remains the gold standard for diagnosis. These disorders are potentially treatable with proper diagnosis and initiation of therapy. Goals of treatment are to eliminate inflammation, restore muscle performance, reduce morbidity, and improve quality of life. This review aims to provide a basic diagnostic approach to patients with suspected IIM, summarize current therapeutic strategies, and provide an insight into future prospective therapies.

Recent Treatment of Interstitial Lung Disease with Idiopathic Inflammatory Myopathies

Interstitial lung disease (ILD) is a prognostic factor for poor outcome in polymyositis (PM)/dermatomyositis (DM). The appropriate management of ILD is very important to improve the prognosis of patients with PM/DM. ILD activity and severity depend on the disease subtype. Therefore, clinicians should determine therapeutic strategies according to the disease subtype in each patient with PM/DM. Anti-melanoma differentiation-associated gene 5 antibody and hyperferritinemia predict the development and severity of rapidly progressive (RP) ILD, particularly in East Asian patients. Combination therapy with corticosteroids, intravenous cyclophosphamide pulse, and calcineurin inhibitors should be administered in RP-ILD. In contrast, patients with anti-aminoacyl-tRNA synthetase (ARS) show better responses to corticosteroids alone. However, ILDs with anti-ARS often display disease recurrence or become refractory to corticosteroid monotherapy. Recent studies have demonstrated that the administration of tacrolimus or rituximab in addition to corticosteroids may be considered in ILD patients with anti-ARS. Large-scale, multicenter randomized clinical trials should be conducted in the future to confirm that the aforementioned agents exhibit efficacy in ILD patients with PM/DM. The pathophysiology of ILD with PM/DM should also be elucidated in greater detail to develop effective therapeutic strategies for patients with ILD in PM/DM.

Cutaneous dermatomyositis: an updated review of treatment options and internal associations

Dermatomyositis is a specific type of inflammatory myopathy with characteristic cutaneous findings. Patients may have skin disease without clinically apparent muscle disease, but this disorder is best thought of as a systemic process. Therefore, all patients with dermatomyositis skin lesions need appropriate evaluation for muscle disease, esophageal dysfunction, cardiopulmonary disease, and potential internal malignancy. There are many therapies that have been used for patients with dermatomyositis, but most are based upon case series or expert opinion rather than meta-analyses or randomized, placebo-controlled trials. Even those therapies that have been subjected to randomized, blinded, placebo-controlled trials include a mixture of patients with idiopathic inflammatory myopathy and do not utilize a validated assessment tool for measuring cutaneous disease responses. In this review, we discuss the therapies available as well as the internal associations with dermatomyositis.

Classification, diagnosis, and management of idiopathic inflammatory myopathies

The detection and characterization of a large array of autoantibodies, including at least 8 different antisynthetase, anti-SRP, -200/100 (HMGCR), -Mi-2, -CADM-140 (MDA5), -SAE, -p155, -MJ (NXP-2), and -PMS1, frequently associated with distinct and well-defined clinicopathological features, allowed for significant improvement in the definition and diagnosis of idiopathic inflammatory myopathies (IIM). Classification remains difficult, with lingering divergence between the different specialties involved in IIM care, but several categories clearly stand out, including dermatomyositis (DM), overlap myositis (OM), polymyositis, necrotizing myositis, and sporadic inclusion body myositis (s-IBM). Biopsy and histological analysis remain crucial, particularly in the absence of autoantibodies, to accurately specify the diagnosis and rule out mimics such as muscular dystrophies and metabolic myopathies. Numerous infectious agents (in particular human immunodeficiency virus and human T cell lymphotrophic virus-1) and drugs (statins, tumor necrosis factor inhibitors, and proton pump inhibitors) can cause mimic IIM that must also be excluded. Pharmacological treatment, in addition to glucocorticoids and immunoglobulins, now includes mycophenolate mofetil and rituximab, which proved helpful in resistant cases, particularly rituximab in DM and OM. Exercise, initially seen as potentially deleterious, recently was shown to be efficacious and safe. IIM can thus be reasonably well controlled in most cases, although aggressive disease remains refractory to treatment, including some cases of necrotizing myopathy. Sporadic IBM still seems resistant to all medications tested to date.

Idiopathic inflammatory myopathies: current trends in pathogenesis, clinical features, and up-to-date treatment recommendations

Recently, there have been important advances in the understanding of the pathophysiologic features, assessment, and management of patients with a newly diagnosed idiopathic inflammatory myopathy (IIM). Myositis-specific autoantibodies have been identified to define patient subgroups and offer prognostic implications. Similarly, proinflammatory cytokines, such as interleukin 6 and type 1 interferon-dependent genes, may serve as potential biomarkers of disease activity in adult and juvenile patients with dermatomyositis (DM). Moreover, magnetic resonance imaging has become an important modality for the assessment of muscle inflammation in adult IIM and juvenile DM. Immune-mediated necrotizing myopathies also are being recognized as a subset of IIM triggered by medications such as statins. However, confusion exists regarding effective management strategies for patients with IIM because of the lack of large-scale, randomized, controlled studies. This review focuses primarily on our current management and treatment algorithms for IIM including the care of pediatric patients with juvenile DM. For this review, we conducted a search of PubMed and MEDLINE for articles published from January 1, 1970, to December 1, 2011, using the following search terms: idiopathic inflammatory myopathies, dermatomyositis, polymyositis, juvenile dermatomyositis, sporadic inclusion body myositis, inclusion body myositis, inflammatory myositis, myositis, myopathies, pathogenesis, therapy, and treatment. Studies published in English were selected for inclusion in our review as well as additional articles identified from bibliographies.

Treatment of interstitial lung diseases associated with connective tissue diseases

A variety of interstitial lung diseases (ILDs) have been reported in association with connective tissue diseases (CTDs). ILD is commonly associated with multiple CTDs and accounts for significant morbidity and mortality in these conditions. In rheumatoid arthritis and systemic sclerosis, ILD commonly occurs in the course of these disorders (incidence: 20-44%). The pathological findings of ILDs are similar to those of idiopathic interstitial pneumonia. A wide variety of histopathologic features, such as various types of interstitial pneumonia and airway involvement, have been observed that are specific for ILDs in rheumatoid arthritis, and this high variety makes its pathology complicated. The diagnosis of ILD is generally based on clinical presentation, bronchioalveolar lavage fluid and high-resolution computed tomography, among others. The most important differential diagnosis is infection, especially pneumocystis pneumonia, and treatment-related toxic damage. The immunosuppressive agents most widely used for the treatment of ILDs are cyclophosphamide, azathioprine, mycophenolate mofetil and calcineurin inhibitors. Other therapeutic strategies are currently being extensively studied, such as antifibrotic agents, endothelin-1 receptor antagonists, tyrosine kinase inhibitors and newer biological agents. In this article, we describe novel therapies for ILDs associated with CTDs.

Diffuse alveolar damage in patients with dermatomyositis: a six-case series

The clinical course of diffuse alveolar damage (DAD) was studied in six consecutive cases of dermatomyositis (DM) based on our hospital records over 8 years. Three patients had severe myopathy at presentation, and the other three patients showed clinically amyopathic DM (CADM). Interstitial pneumonia in all patients developed shortly after they manifested DM. DAD in five deceased patients, which was proven pathologically, did not respond to steroid therapy combined with cyclosporine or tacrolimus. Of these, two patients began receiving combination therapy before suffering respiratory symptoms, and one of them had elevated serum Krebs von der Lungen-6 (KL-6) levels before visible abnormalities appeared on a plain chest X-ray. Only one patient with CADM survived; this patient received intravenously administered pulse cyclophosphamide (IVCY) therapy intravenously for DAD from the early stage. Delayed adjunctive IVCY was ineffective for progressed DAD in the remaining five patients. Elevated serum ferritin levels were observed in all four patients examined and might have predicted the lethal DAD, as in a previous report. In conclusion, promptly beginning IVCY therapy may be beneficial for patients with DM and interstitial pneumonia who show elevated serum levels of ferritin or KL-6 with minimal pulmonary abnormalities.

The use of cyclosporine in dermatology: part I

Cyclosporine is a calcineurin inhibitor that acts selectively on T cells. It has been used in dermatology since 1997 for its US Food and Drug Administration indication of psoriasis and off-label for various other inflammatory skin conditions, including atopic dermatitis, blistering disorders, and connective tissue diseases. In the last decade, many dermatologists have hesitated to use this important drug in their clinical practices because of its toxicity profile. The purpose of this article is to review the mechanism of action of cyclosporine and its current uses and dosing schedules. It is our goal to create a framework in which dermatologists feel comfortable and safe incorporating cyclosporine into their prescribing regimens.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to describe the mechanism of action of cyclosporine, recognize the potential role of cyclosporine in dermatology and the evidence to support this role, and incorporate cyclosporine into his or her prescribing regimens.

Polymyositis/dermatomyositis and interstitial lung disease: A new therapeutic approach with T-cell-specific immunosuppressants

Interstitial lung disease (ILD) is a common complication of polymyositis (PM) and dermatomyositis (DM), and accounts for a significant proportion of their morbidity and mortality because of the resistance to therapeutic agents including corticosteroids. Its pathogenic mechanism is not known, but several studies have provided findings implicating that T-cells, especially activated CD8+ cells, may play essential roles, and thus could be therapeutic targets in this disease. To test this hypothesis, we began clinical investigation of the efficacy of T-cell-specific immunosuppressants, cyclosporine (CsA) and FK506, in PM/DM patients with ILD. In our retrospective nationwide multi-center study compiling a total of 53 patients, a combination of CsA and corticosteroids resulted in favorable early and long-term outcome in the majority of patients except for DM patients with acute ILD. In this subset, those who received the combination as an initial therapy had better survival than those who initially received corticosteroids alone. FK506 has a similar mode of action but is up to 100-fold more potent than CsA in vitro, and has been used in more refractory ILD cases. We next reviewed 5 PM/DM patients with ILD who failed on various immunosuppressants including CsA and were subsequently treated with FK506 in our hospital, and found that 3 improved promptly, 1 gradually and steadily, and another case responded slowly after prednisolone dose was increased. None developed adverse effects. In summary, these T-cell targeted therapies have a potential to be the cornerstone of the treatment for ILD in PM/DM patients. The combination therapy with CsA and corticosteroids may be efficacious especially when used early. FK506 may be advantageous even in refractory cases to CsA. These findings indicate that further investigation is warranted. Currently, prospective investigation of FK506 is underway.

Transient elevation of the tumor markers CA 15-3 and CASA as markers of interstitial lung disease rather than underlying malignancy in dermatomyositis sine myositis

A 37-year-old woman with severe interstitial lung disease associated with dermatomyositis sine myositis is reported. A thoracoscopic lung biopsy revealed organizing diffuse alveolar damage. Significantly elevated serum levels of the tumor markers CA 15-3 and CASA (cancer-associated serum antigen) were detected, but no evidence of an underlying malignancy (including breast and ovarian) was found on serial clinical and radiologic examinations. These levels gradually normalized as the interstitial lung disease responded to a combination of cyclophosphamide and corticosteroids. The use of the CA 15-3 and CASA assays to measure serum levels of the highly glycosylated, high-molecular-weight mucin MUC1 in interstitial lung disease has not been previously described. Clinicians should therefore be aware that elevation of these tumor markers may reflect the presence of interstitial lung disease rather than an underlying malignancy in patients with dermatomyositis, especially if the levels normalize after successful treatment of the lung disease.

Human urinary trypsin inhibitor bolus infusion improved severe interstitial pneumonia in mixed connective tissue disease

Interstitial pneumonia (IP) with mixed connective tissue disease (MCTD) often progresses despite immunosuppressive therapies that caused serious infections. Human urinary trypsin inhibitor (UT) inhibits inflammatory factors associated with IP, without immunosuppression. UT bolus infusion rescued a female MCTD patient with refractory IP and severe opportunistic fungal pneumonia. Her IP diminished with monthly UT bolus infusion despite tapering of prednisolone, without UT-related side effects. UT pulse therapy could prove beneficial for refractory IP in MTCD even with opportunistic infections.

Step-up versus primary intensive approach to the treatment of interstitial pneumonia associated with dermatomyositis/polymyositis: a retrospective study

Corticosteroids (CS) are the standard initial treatment for interstitial pneumonia (IP) associated with dermatomyositis (DM)/polymyositis (PM). However, many patients fail to respond and have significantly high mortality even if immunosuppressive drugs (ISDs) are subsequently added, while a more intensive initial approach using ISDs is suggested to improve their survival. We conducted a retrospective study to examine the association between initial therapeutic approaches and clinical outcomes of active IP in DM/PM patients. We reviewed medical records of 34 consecutive DM/PM patients who had active IP defined by the presence of pulmonary function abnormality or active symptoms, and compared clinical outcome between those patients to whom ISDs were added if CS alone did not result in a favorable response (a step-up approach) and those who were started on ISDs simultaneously with CS (a primary intensive approach). Clinical endpoints were death, pulmonary death, and progression or improvement of pulmonary function. The step-up approach was used in 20 patients, to 11 of whom ISDs were eventually added after a median of 2.0 weeks, while the primary intensive approach was used in 14 patients. The primary intensive approach group had significantly better survival than the step-up approach group (P = 0.030 by the log-rank test). These two groups did not differ significantly in demographic characteristics and baseline clinical and laboratory features. Intensive approach by starting ISDs simultaneously with CS in the initial treatment for active IP in DM/PM patients was associated with better survival, emphasizing the impact of initial treatment on their survival. Prospective clinical investigation of this approach is now needed, but the limited clinical utility of CS as an initial treatment might ethically challenge clinical-trial designing.

A Case of Hypomyopathic Dermatomyositis Associated with Rapid Progressive Interstitial Pneumonia Resistant to Multi-immunosuppressive Therapy

The prognosis of interstitial pneumonia in patients with dermatomyositis is thought to depend on the histologic type and response to therapy. We report a case of hypomyopathic dermatomyositis with rapid development of a fatal interstitial pneumonia. Although the histology of lung biopsy indicated minimal alveolitis, the patient died despite multi-immunosuppressive therapy. The autopsy revealed acute and organizing diffuse alveolar damage. In this case, the lung biopsy taken before the acute deterioration did not predict the patient's poor prognosis. Interstitial pneumonia in patients with amyopathic or hypomyopathic dermatomyositis would develop rapidly progressive and refractory. We need larger and better prospective studies to determine whether early and intensive immunosuppressive therapy improves the prognosis of interstitial pneumonia in patients with amyopathic or hypomyopathic dermatomyositis.

Treatment of refractory polymyositis and dermatomyositis

Polymyositis (PM) and dermatomyositis (DM) are autoimmune inflammatory diseases that primarily target muscle. Although similar, PM and DM have different pathophysiologic mechanisms. Current therapy for PM and DM does not take into account these pathophysiologic differences. Recent work has started to define outcome measures to apply to future therapeutic trials, which will allow better comparison of treatment outcomes. For patients who are unresponsive to standard therapy with high dose prednisone supplemented by methotrexate and/or azathioprine it is not clear what represents the next best choice for therapy. Although there are few controlled studies in the area, there is reason to be optimistic for use of intravenous methylprednisolone pulses, intravenous gammaglobulin, cyclosporine A, tacrolimus, mycophenolate mofetil, and rituximab for nonresponding patients. Better understanding of the underlying pathophysiology of PM and DM, as well as carefully performed multicenter clinical trials is going to be necessary to make better recommendations in the future.

Treatment of inflammatory myopathies

Idiopathic inflammatory myopathies, notably polymyositis and dermatomyositis are comparatively uncommon diseases and few randomised, double blind placebo controlled trials have been done. Final validation of measures to assess outcome and response to treatment is awaited. Corticosteroids are an effective initial treatment, although rarely tested in randomised controlled trials. Unfortunately, not all patients respond to them and many develop undesirable side effects. There is thus a need for second line agents notably immunosuppressives or intravenous immunoglobulin. There are no defined guidelines or best treatment protocols agreed internationally and so the medical approach must be individualised, based on the severity of clinical presentation, disease duration, presence of extramuscular features, and prior therapy and contraindications to particular agents. There is still a significant percentage of non-responders (around 25%) and clinical relapses. Novel therapeutic approaches are now directed towards cytokine modulation and the use of monoclonal antibodies targeting B and T cells.

Atteinte pulmonaire au cours des polymyosites et des dermatomyosites

Interstitial lung disease is a serious complication of polymyositis/dermatomyositis and leads to death from chronic respiratory insufficiency in 30 to 66% of cases. It is a criterion of poor prognosis in these disorders. Its onset occurs at variable points in the course of polymyositis/dermatomyositis, and precedes them in half of all cases. Presentation may also vary: acute (25%), insidious (60%), or infraclinical, discovered fortuitously (15%). The examinations of choice for early screening are high-resolution computed tomography (CT) and pulmonary function tests, which should be performed during the initial work-up and during ongoing surveillance. Moreover, high-resolution CT also makes it possible to determine the type of histologic lesions in the interstitial lung disease. Today, diagnosis of this disease does not generally require histological confirmation; nonspecific interstitial lung disease seems to be the most common histologic form of lung damage in polymyositis/dermatomyositis (40 to 80%). Anti-Jo1 antibodies are a sensitive marker of interstitial lung disease during polymyositis/dermatomyositis, and close surveillance of lung function is recommended in patients with these autoantibodies. Systematic testing for them is also justified in patients with apparently idiopathic interstitial lung disease, to rule out underlying polymyositis/dermatomyositis. No clear treatment protocols have been established for interstitial lung disease during polymyositis/dermatomyositis. Corticosteroid treatment is the first choice. Its combination with cyclophosphamide may be most effective in corticosteroid-resistant forms of polymyositis/dermatomyositis, especially when begun early; it may also be appropriate to begin corticosteroids as soon as factors predicting poor prognosis are detected.

Polymyositis/dermatomyositis-associated lung disease: analysis of a series of 81 patients

The objective of this study was to assess the prevalence, clinical, histological and immunological characteristics, and the long-term outcome of polymyositis- (PM) and dermatomyositis- (DM) associated lung disease, and to define subgroups of lung-associated inflammatory myopathies. This retrospective study included 81 consecutive patients diagnosed with PM/DM. Pulmonary involvement was systematically investigated in relation to clinical symptoms by chest radiography, high resolution computed tomography and pulmonary function testing. Anti-synthetase autoantibodies (ASA) were analysed by ELISA and confirmed by protein and RNA immunoprecipitation methods. Statistical analyses were done with the Student t-test and Fisher exact test. Cumulative survival probabilities were estimated by the Kaplan-Meier method and Cox regression analysis. Fifty patients (61%) presented pulmonary involvement. Thirty-two (39%) had interstitial lung disease and five of them had devastating acute interstitial pneumonia with pneumomediastinum and an unfavorable prognosis. Histology showed diffuse alveolar damage in this subgroup and ASA were negative. Eighteen patients (22%) presented restrictive myopathic lung disease; in three of them respiratory muscles could not maintain ventilation. ASA were positive in 17 of the 50 patients (34%) and were significantly associated with interstitial lung disease (OR: 4.5 [95% CI: 1.3-15.3]), arthritis (OR: 6.0 [95% CI: 1.3-29.2]) and 'mechanic hands' (OR: 8.5 [95% CI: 1.7-41.4]); the presence of these autoantibodies did not imply worse survival prognosis. We concluded that clinical and immunological characteristics allowed the grouping of patients into different types of PM/DM lung-associated disease. Presence of ASA did not affect survival. ASA-negative patients with acute interstitial pneumonitis and pneumomediastinum had an unfavorable prognosis.

Interstitial lung disease in patients with polymyositis, dermatomyositis and amyopathic dermatomyositis

OBJECTIVE

To assess the prevalence, characteristics and prognostic factors of interstitial lung disease (ILD) in Korean patients with polymyositis (PM), dermatomyositis (DM) and amyopathic dermatomyositis (ADM).

METHODS

We reviewed the medical records of 72 consecutive PM and DM patients, including six patients with ADM, who were seen at the Rheumatology Clinic of Seoul National University Hospital between 1984 and 2003.

RESULTS

Twenty-nine PM/DM patients (40.3%) developed ILD. Anti-Jo-1 antibody and arthralgia were associated with the presence of ILD (P = 0.022 and P = 0.041, respectively), whereas dysphagia was more frequently found in patients without ILD (P = 0.041). Lung biopsies revealed diffuse alveolar damage (DAD) (n = 2), usual interstitial pneumonia (UIP) with DAD (n = 2), UIP (n = 1), and non-specific interstitial pneumonia (n = 2). Of the 29 patients, 11 (37.9%) died. The mean survival time in ILD patients was significantly shorter than in those without ILD (13.8+/-1.8 vs 19.2+/-0.9 yr, P = 0.017). Poor survival in ILD patients was associated with a Hamman-Rich-like presentation (P = 0.0000), ADM features (P = 0.0001) and an initial forced vital capacity (FVC) < or =60% (P = 0.024).

CONCLUSIONS

ILD was observed in 40.3% of Korean PM/DM patients and was associated with poor survival. A Hamman-Rich-like presentation, ADM features and an initial FVC < or =60% were associated with poor survival in ILD.

Life-threatening dermatoses due to connective tissue disorders

Connective tissue disorders such as scleroderma, dermatomyositis and lupus erythematosus are autoimmune, multi-system disorders whose clinical manifestations can be restricted to the skin or may involve many organs. The degree and rate of organ system involvement defer, as does the prognosis and rapidity of disease progression. In this article, scleroderma, dermatomyositis and lupus erythematosus will be reviewed in respect to their life-threatening potential.

Interstitial lung disease in polymyositis and dermatomyositis

Interstitial lung disease occurs in approximately one-third of patients with polymyositis and dermatomyositis (PM/DM) and has an adverse effect on survival. It is commonly a component of early PM/DM and can precede the onset of muscle or skin disease. Its most common histopathology is nonspecific interstitial pneumonia. This is a more benign pattern, with respect to response to immunosuppression and also long-term survival, than the pattern of usual interstitial pneumonia seen in idiopathic pulmonary fibrosis. The clinical course of PM/DM lung disease is heterogeneous. Progressive and nonprogressive disease needs to be distinguished by clinical and physiologic monitoring to avoid over-treatment. Patients with ongoing functional deterioration mostly benefit from immunosuppression. The experience with corticosteroid monotherapy is discouraging but cyclophosphamide, given as daily oral or intravenous pulse therapy together with corticosteroids, was found to be beneficial in many patients. Other immunosuppressants may be of benefit as well, but the weight of the current evidence supports the use of cyclophosphamide first.

Inflammatory myopathies: clinical, diagnostic and therapeutic aspects

The three major forms of immune-mediated inflammatory myopathy are dermatomyositis (DM), polymyositis (PM), and inclusion-body myositis (IBM). They each have distinctive clinical and histopathologic features that allow the clinician to reach a specific diagnosis in most cases. Magnetic resonance imaging is sometimes helpful, particularly if the diagnosis of IBM is suspected but has not been formally evaluated. Myositis-specific antibodies are not helpful diagnostically but may be of prognostic value; most antibodies have low sensitivity. Muscle biopsy is mandatory to confirm the diagnosis of an inflammatory myopathy and to allow unusual varieties such as eosinophilic, granulomatous, and parasitic myositis, and macrophagic myofasciitis, to be recognized. The treatment of the inflammatory myopathies remains largely empirical and relies upon the use of corticosteroids, immunosuppressive agents, and intravenous immunoglobulin, all of which have nonselective effects on the immune system. Further controlled clinical trials are required to evaluate the relative efficacy of the available therapeutic modalities particularly in combinations, and of newer immunosuppressive agents (mycophenolate mofetil and tacrolimus) and cytokine-based therapies for the treatment of resistant cases of DM, PM, and IBM. Improved understanding of the molecular mechanisms of muscle injury in the inflammatory myopathies should lead to the development of more specific forms of immunotherapy for these conditions.

Interstitial lung disease in polymyositis and dermatomyositis: clinical course and response to treatment

OBJECTIVES

To assess the prevalence, clinical characteristics, and treatment options of patients with interstitial lung disease (ILD) in polymyositis and dermatomyositis (PM/DM).

PATIENTS AND METHODS

Sixty-three consecutive patients with PM/DM underwent standardized screening. Patients with ILD were monitored prospectively, and graded immunosuppression was administered according to the rate of clinical progression.

RESULTS

ILD was diagnosed in 20 of 63 patients (32%). Generally, the clinical and serologic findings of the anti-Jo1 syndrome were present. Follow-up evaluation disclosed either a progressive or a nonprogressive course. The 10 patients with progressive ILD were distinguished from the nonprogressive group by extensive ground-glass opacities on high-resolution computed tomography (HRCT) and by bronchoalveolar lavage (BAL) neutrophilia. Intravenous pulse cyclophosphamide prevented further progression in all 10 patients and led to some functional improvement. In the 10 patients without rapidly progressive lung disease, immunosuppression of moderate intensity stabilized pulmonary findings during a median 35 months of follow-up.

CONCLUSIONS

The prevalence of ILD in our patients with PM/DM was 32%; this emphasizes the need for pulmonary screening in all PM/DM patients. Progressive disease, featuring ground-glass opacities on HRCT and an inflammatory BAL cell profile, is amenable to intensive immunosuppression. Conversely, patients who do not have these HRCT and BAL features appear to have a low risk of pulmonary deterioration.

RELEVANCE

Because the treatment for ILD seems to depend on the rate of clinical progression, future therapeutic trials of lung disease in PM/DM should stratify patients accordingly.

Interstitial lung disease in polymyositis and dermatomyositis

OBJECTIVES

To assess prevalence, characteristics, and long-term outcome of interstitial lung disease (ILD) in polymyositis (PM) and dermatomyositis (DM). To determine predictive variables of ILD course in PM/DM, and to define both clinical and biochemical features associated with ILD onset in PM/DM.

METHODS

The medical records of 156 consecutive PM/DM patients in 3 medical centers were reviewed.

RESULTS

Thirty-six PM/DM patients (23.1%) developed ILD. We observed that 19.4% of patients with ILD had resolution of pulmonary disorders, whereas 25% experienced ILD deterioration. Morbidity and mortality rates were as high as 13.9% and 36.4%, respectively, in PM/DM patients with ILD. Parameters of PM/DM that related to ILD poor outcome were identified as follows: Hamman-Rich-like pattern, initial diffusing capacity of carbon monoxide <45%, neutrophil alveolitis, and histologic usual interstitial pneumonia. Additionally, for the group with ILD, polyarthritis, higher values of erythrocyte sedimentation rate and C-reactive protein, presence of anti-Jo-1 antibody, and characteristic microangiopathy were significantly more frequent.

CONCLUSION

Our series underlines the high frequency of ILD in PM/DM patients, resulting in increased morbidity and mortality rates. It also indicates that PM/DM patients should routinely be screened for ILD, even those patients without anti-Jo-1 antibody, because 69% of our ILD patients were seronegative for the anti-Jo-1 antibody. Our findings further suggest that PM/DM patients presenting with factors predictive of ILD poor outcome may require more aggressive therapy.

Critical requirement for professional APCs in eliciting T cell responses to novel fragments of histidyl-tRNA synthetase (Jo-1) in Jo-1 antibody-positive polymyositis

Polymyositis (PM) is an autoimmune muscle disease characterized by oligoclonal T cell infiltrates mediating myocytotoxicity. Although antigenic triggers for this process remain undefined, clinically homogeneous subsets of PM patients are characterized by autoantibodies directed against nuclear and cytoplasmic Ags that include histidyl-tRNA synthetase (Jo-1). Available evidence suggests that formation of anti-Jo-1 autoantibodies is Ag-driven and therefore dependent on CD4(+) T cells that may also direct cytolytic CD8(+) T cells involved in myocyte destruction. To assess peripheral blood T cell responses to Jo-1, we first subcloned full-length human Jo-1 as well as novel fragments of Jo-1 into the maltose-binding protein expression vector pMALc2. Expressed proteins were then used in standard proliferation assays with either PBMC or autologous DCs as sources of APCs. Although PBMC-derived APCs and DCs both supported peripheral blood T cell proliferation when primed with full-length human Jo-1, only DCs promoted proliferative responses to a unique amino-terminal fragment of Jo-1. mAb blockade of different HLA Ags revealed that these responses were MHC class II dependent. Therefore, for the first time, these studies demonstrate anti-Jo-1 T cell responses in Jo-1 Ab-positive PM patients as well as in healthy control subjects. More importantly, this work underscores the critical importance of APC type in dictating T cell responses to a novel antigenic fragment of Jo-1.

Idiopathic inflammatory myopathy: management and prognosis

We are entering an exciting era in our understanding and management of the connective tissue diseases and, in particular, inflammatory myopathy. There is an established array of immunosuppressive regimens available to clinicians; rehabilitative and physical therapeutic interventions are evolving to provide many nonpharmacologic options to complement current therapy. Our ability to quantify [table: see text] the disease burden, using newly developed tools to distinguish myositis disease activity from disease damage, will allow us to measure with greater sensitivity the effects of treatment interventions. These measures, together with the development of international consensus regarding the standardization of many clinical trial design parameters, will enhance our capacity to conduct well-designed, prospective, multicenter studies of established and newly developed therapies. The explosion of immunopathogenetic information, in conjunction with novel biologic agents (Table 4), will afford investigators a treatment menu with multiple therapeutic options. The continuing challenge for the practitioner is the development of a logical, well-studied, multifaceted, and multidisciplinary holistic approach that optimizes the risk: benefit ratio for each individual patient and uses a rational combination of immunomodulatory agents in conjunction with ancillary measures.

Pulmonary complications of inflammatory myopathy

Pulmonary manifestations contribute significantly to the morbidity and mortality of the idiopathic inflammatory myopathies, ranging from intrinsic lung disease to secondary complications that include aspiration pneumonia, opportunistic infection, congestive heart failure, and hypoventilation. Newer classification schemes for interstitial lung disease have permitted closer correlation between histologic subtype and clinical outcome, while diagnostic techniques such as bronchoalveolar lavage have begun to define the cellular elements responsible for immune-mediated pulmonary dysfunction. Investigators have identified several serum markers correlating with inflammatory disease activity in the lung that should enhance noninvasive monitoring of therapeutic responses to newer regimens involving agents such as cyclosporine and tacrolimus. Taken together, these advances have contributed to better understanding of the immunopathogenesis of myositis-associated interstitial lung disease that should ultimately translate into more effective treatment.

Activation of pulmonary T cells in corticosteroid-resistant and -sensitive interstitial pneumonitis in dermatomyositis/polymyositis

To study the activation states and cytokine profiles of pulmonary T cells in corticosteroid-resistant and corticosteroid-sensitive interstitial pneumonitis (IP) in dermatomyositis (DM)/polymyositis (PM), we examined the activation markers and cytokine profiles of T cells in bronchoalveolar lavage fluids (BALF) from patients with IP in DM/PM before prednisolone therapy and then compared the activation states of T cells according to the therapeutic response of IP to prednisolone therapy. CD25+ CD4+ T cells in BALF were significantly increased in both corticosteroid-resistant and corticosteroid-sensitive IP in DM/PM as compared with those in controls without IP. Furthermore, CD25+ CD4+ T cells in BALF were significantly more increased in corticosteroid-resistant IP than those in cortico teroid- sensitive IP. Moreover, CD25+ CD8+ T cells in BALF were significantly increased only in corticosteroid-resistant IP, but not in corticosteroid-sensitive IP or controls without IP. IFN-gamma mRNA was detected in BALF T cells in corticosteroid-resistant and corticosteroid-sensitive IP but not in controls without IP, whereas IL-4 mRNA was virtually undetected in BALF T cells in both the IP groups. However, there were no significant differences in CD4/CD8 ratio of BALF T cells, HLA-DR+ BALF T cells or CD25+ and HLA-DR+ peripheral blood T cells between the two IP groups. These results indicate that activated Th1-type pulmonary T cells play an important role in the development of corticosteroid- resistant IP in DM/PM and that the increase in CD25+ CD8+ T cells in BALF is a useful indicator for corticosteroid-resistant IP in DM/PM and hence may be an indicator for early use of cyclosporin.

Cyclosporin A and intravenous immunoglobulin treatment in polymyositis/dermatomyositis

OBJECTIVE

To describe the treatment of polymyositis (PM) and dermatomyositis (DM) with prednisone (PRED) and cyclosporin A (CSA) alone or associated with intravenous immunoglobulin (IVIg) and plasmapheresis (PEX).

METHODS

Between 1992 and 1999 CSA and PRED were used to treat 20 patients with idiopathic myositis (12 with DM, eight with PM), diagnosed according to the Bohan and Peter criteria. In patients with refractory or relapsed disease, IVIg was added alone (seven cases) or synchronised with PEX (six cases). A standardised protocol was used to evaluate the patients, and assess disease activity and treatment response.

RESULTS

Despite a transient response to PRED and CSA in 16/20 cases, this combination did not induce full remission in 13/20 cases, which led to the IVIg trial with or without PEX. Patients receiving PRED and CSA plus IVIg had a significantly higher probability of maintaining complete remission at the end of the four year follow up period than those treated with PRED and CSA alone (p<0.001). No further benefit was added by the PEX. The presence of arthritis significantly correlated with a poorer response to treatment (p<0.05). Adverse effects were gingival hyperplasia (one patient) and transient renal dysfunction (one).

CONCLUSIONS

This open study suggests that combined treatment with PRED, CSA, and IVIg is useful in patients with myositis, even those with refractory or relapsed disease; no increase in the number or type of side effects is seen.

[Interstitial lung diseases in polymyositis and dermatomyositis]

PURPOSE

Interstitial lung disease is one of the most common respiratory manifestations in polymyositis and dermatomyositis. It still remains a severe complication of the disease, leading to death related to ventilatory insufficiency in 30-66% of patients.

CURRENT KNOWLEDGE AND KEY POINTS

Time onset of interstitial lung disease is variable, although interstitial lung disease onset precedes initial manifestations of polymyositis/dermatomyositis in roughly half of the patients. Moreover, clinical presentation of interstitial lung disease can be dichotomized, according to patients' pulmonary manifestations, into: 1) both acute and aggressive lung disease similar to Hamman-Rich syndrome; 2) slowly progressive lung disease; and 3) an asymptomatic pattern. The methods of choice adopted for early diagnosis of interstitial lung disease are high-resolution computed tomography scan and pulmonary function tests, which should be performed during both initial evaluation of polymyositis/dermatomyositis and follow-up. Because anti-JO1 antibody is considered to be a marker of interstitial lung disease in polymyositis/dermatomyositis, close pulmonary follow-up of anti-JO1-positive patients with polymyositis is therefore required for early detection of subclinical impairment. Furthermore, histological lung findings provide prognostic data; patients with bronchiolitis obliterans organizing pneumonia (BOOP) indeed appear to have a more favorable outcome than those with usual interstitial pneumonia or diffuse alveolar damage. Finally, as a guide to both the severity and progress of interstitial lung disease, the significance of other investigations, notably bronchoalveolar lavage, remains controversial.

FUTURE PROSPECTS AND PROJECTS

Specific therapy of interstitial lung disease has not yet been clearly established in polymyositis/dermatomyositis patients. Corticosteroid therapy is considered the first line of therapy for polymyositis/dermatomyositis patients with interstitial lung disease. The association of cyclophosphamide and corticosteroids may be the most effective in patients with steroid-resistant interstitial lung disease. Early diagnosis and management of this disease is therefore of the utmost importance.

Cyclosporine and tacrolimus in dermatology

Immune modulators are being used with increasing frequency in dermatology. This article reviews two such agents, cyclosporine and tacrolimus. Discussion emphasizes the pharmacology, side effects, and uses of these two drugs in dermatologic disorders.

Interstitial lung disease in polymyositis and dermatomyositis

Interstitial lung disease (ILD) is common in patients with polymyositis (PM) and dermatomyositis (DM), and is a major cause of morbidity. Although its cause is unknown, it is known to be closely associated with autoimmune disorders. Its manifestation has been found to be quite heterogeneous, as demonstrated by the differences among PM/DM patients in their immunologic profiles and histopathologic findings, which suggest variations in immunopathogenetic mechanisms. We review the clinicopathologic and immunologic findings in ILD associated with PM/DM, and discuss recent advances in classification, autoantibodies, and treatment. The most critical issues are to clarify the immunopathogenesis of severe forms of ILD, such as rapidly progressive ILD associated with amyopathic DM, and to establish the most appropriate therapy.

Current approach to the treatment of polymyositis and dermatomyositis

Although corticosteroids remain the mainstay of treatment for the inflammatory myopathies, their use is complicated by many side effects. Other immunosuppressive agents, alone or in combination, are being increasingly used for patients with other severe disease or treatment-related complications. Pulmonary disease remains a serious source of morbidity and mortality in myositis patients. Cyclophosphamide, cyclosporine, and tacrolimus are efficacious in patients with interstitial lung disease. Intravenous immunoglobulin is not only effective for the cutaneous complications of dermatomyositis but has been helpful in other extramuscular manifestations.