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Tang K, Zhou J, Lan Y, Zhang H, Jin H. Pregnancy in adult-onset dermatomyositis/polymyositis: a systematic review. Am J Reprod Immunol 2022; 88:e13603. [PMID: 35867856 DOI: 10.1111/aji.13603] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/16/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
Idiopathic inflammatory myopathy in pregnancy is uncommon but may result in complications for both mother and the fetus. In this systematic review, we summarized the current literature investigating outcomes of pregnancy related to the dermatomyositis/polymyositis (DM/PM) process. We searched PubMed, Embase, Cochrane Library, and Web of Science databases and included 61 studies reporting the disease course, pregnancy outcomes, and management of both pregnancy and DM/PM in the final analysis. The specific information of 221 pregnancies was extracted and these pregnancies were divided into three distinct forms: pregnancies after disease onset (n = 159), pregnancies with new disease onset (n = 37), and pregnancies followed by postpartum onset (n = 25). In most cases, DM/PM disease activity remained stable or improved throughout pregnancy (80.2%) and the postpartum period (83.9%). Active DM/PM during pregnancy significantly increased the risk of stillbirth or neonatal death (12% vs. 1%, P = 0.005) and preterm birth (34.7% vs. 11%, P<0.001). The rates of other poor outcomes (total fetal loss, low birth weight, and intrauterine growth retardation) were also increased in pregnancies with active disease. Mainstay treatments for active DM/PM during pregnancy are glucocorticoids and intravenous immunoglobins. The present results underline the importance of good control of myopathy in optimizing the pregnancy outcomes of women with DM/PM. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Keyun Tang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jia Zhou
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yining Lan
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hanlin Zhang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hongzhong Jin
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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2
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Ito Y, Yamamoto Y, Suzuki Y, Noda K, Nakajima A. Clinical and Serological Features and Pregnancy Outcomes in Women with Polymyositis/Dermatomyositis: A Case-based Review. Intern Med 2022; 61:143-149. [PMID: 34334572 PMCID: PMC8851185 DOI: 10.2169/internalmedicine.7924-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/20/2021] [Indexed: 11/29/2022] Open
Abstract
We encountered a 30-year-old woman who developed dermatomyositis during pregnancy and was positive for anti-Mi-2 antibodies. She was successfully treated with prednisolone and tacrolimus and delivered a healthy child. We reviewed the cases of idiopathic inflammatory myositis (IIM) that developed during pregnancy that were published after the year 2000 to elucidate the profile of myositis-specific antibodies (MSAs) in them and to evaluate their obstetric outcomes. In cases with IIM that developed during pregnancy, anti-Mi-2, anti-TIF1-g, anti-Jo-1, and anti-EJ antibodies was detected in one case each. The obstetric outcomes of the IIM-complicated pregnancies were poor, especially when complicated with active maternal myositis. Further studies focusing on the possible causal relationships between MSAs and cases with IIM that developed during pregnancy are needed. For better obstetric outcomes, appropriate suppression of the maternal disease activity using immunosuppressants and vigilance regarding the patient's requirement of Caesarean section is important.
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Affiliation(s)
- Yuhei Ito
- Center for Rheumatic Diseases, Mie University Hospital, Japan
| | | | - Yasuo Suzuki
- Center for Rheumatic Diseases, Mie University Hospital, Japan
| | - Kentaro Noda
- Center for Rheumatic Diseases, Mie University Hospital, Japan
| | - Ayako Nakajima
- Center for Rheumatic Diseases, Mie University Hospital, Japan
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3
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Akiyama C, Shirai T, Sato H, Fujii H, Ishii T, Harigae H. Association of various myositis-specific autoantibodies with dermatomyositis and polymyositis triggered by pregnancy. Rheumatol Int 2021; 42:1271-1280. [PMID: 33837447 DOI: 10.1007/s00296-021-04851-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/27/2021] [Indexed: 01/05/2023]
Abstract
Although pregnancy is an important risk factor for autoimmune rheumatic diseases, little is known regarding the association between pregnancy and dermatomyositis (DM) or polymyositis (PM). Herein, we present two patients with DM that developed during the perinatal period. The first patient was positive for anti-aminoacyl synthetase (ARS) antibody and developed DM in the 14th week of pregnancy. Despite treatment, her foetus died of intrauterine growth restriction in the 27th week. The second patient was positive for anti-melanoma differentiation-associated gene 5 (MDA-5) antibody and developed DM 1 week after miscarriage at 9 weeks of gestation. The patient developed severe interstitial pneumonia, and intensive therapy including tofacitinib and rituximab administration was required. Our cases and a literature review revealed that various myositis-specific autoantibodies, including anti-ARS, anti-Mi-2, anti-TIF-1γ, and anti-MDA-5, are associated with DM and PM triggered by pregnancy. We also found that delay in commencing treatment in case of active disease including myositis and interstitial pneumonia, and poor response to corticosteroids were related to poor foetal outcomes in DM and PM. Although rare in pregnant women, it is critical to consider the possibility of DM and PM in patients presenting with rash, fever, weakness, and cough, and testing for myositis-specific autoantibodies is recommended.
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Affiliation(s)
- Chikaho Akiyama
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Hiroko Sato
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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4
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Mahmood I, Tegenge MA, Golding B. Considerations for Optimizing Dosing of Immunoglobulins Based on Pharmacokinetic Evidence. Antibodies (Basel) 2020; 9:E24. [PMID: 32575458 PMCID: PMC7345246 DOI: 10.3390/antib9020024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/07/2020] [Accepted: 06/17/2020] [Indexed: 12/18/2022] Open
Abstract
Immunoglobulins (IGs) are widely used for the treatment of immunodeficiency syndromes and several autoimmune diseases. In neonates, IGs have been used for the treatment of alloimmune thrombocytopenia, in neonatal infections and in the rare cases of neonatal Kawasaki disease. This review aims to examine the various dosing regimens of IGs following intravenous (IV) and subcutaneous (SC) administration, pharmacokinetics (PK) of IGs, and the importance of trough values for the prevention of infections in patients with primary immune deficiency (PID). The review also focuses on the mechanism of catabolism of IGs and the impact on the half-life of IGs. Data and reviews were obtained from the literature and the FDA package inserts. The authors suggest that for dosing, the PK of IGs should be evaluated on the baseline-corrected concentrations since this approach provides an accurate estimate of half-life and clearance of IGs. We also suggest employing clearance as a primary PK parameter for dosing determination of IGs. We suggest that IV dosing would be more effective if given more frequently to adjust for the increased clearance at high doses and because the baseline-corrected half-life is much shorter than the baseline-uncorrected half-life. Regarding SC administration, the dose should be adjusted based on the absolute bioavailability (determined against IV dosing) of the product. Finally, we highlight clinical and PK data gaps for optimum and individualized dosing of IGs.
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Affiliation(s)
- Iftekhar Mahmood
- Division of Clinical Evaluation and Pharmacology/Toxicology, Office of Tissue and Advanced Therapies (OTAT), Center for Biologics Evaluation and Research (CBER), Food & Drug Administration (FDA), 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA
| | - Million A. Tegenge
- Office of Biostatistics & Epidemiology, Center for Biologics Evaluation and Research (CBER), Food & Drug Administration (FDA), 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA;
| | - Basil Golding
- Division of Plasma Protein Therapeutics, Office of Tissue and Advanced Therapies (OTAT), Center for Biologics Evaluation and Research (CBER), Food & Drug Administration (FDA), 10903 New Hampshire Avenue, Silver Spring, MD 20993-0002, USA;
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Chou YL, Hsieh KH, Perng CL, Fan HC, Tien CH, Wang CC, Chen SJ, Chang FW. High level antibodies to TORCH in the IVIG preparation from Taiwanese. J Chin Med Assoc 2019; 82:510-514. [PMID: 31180949 DOI: 10.1097/jcma.0000000000000043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Congenital TORCH (toxoplasmosis, other viruses [varicella-zoster virus, VZV, etc.], rubella, cytomegalovirus [CMV], Herpes simplex virus [HSV]) infections are major causes of prenatal, perinatal, and postnatal morbidity and mortality. Although treatment or prevention strategies are available for these pathogens, all drugs may not be safe during the pregnancy. The aim of this study is to measure the antibodies (Abs) concentration in the intravenous immunoglobulin (IVIG) preparation to evaluate the therapeutic potential for TORCH infection. METHODS We tested the only one commercial IVIG preparation from Taiwanese for the presence of Abs against Toxoplasma gondii, VZV, Epstein-Barr virus (EBV), measles, mumps, rubella, CMV, HSV type 1 (HSV-1), and HSV type 2 (HSV-2) by using enzyme-linked immunosorbent assay or chemiluminescent microparticle immunoassay. RESULTS In our study, the median level (range) of anti-CMV immunoglobulin G (IgG) is > 250 (All > 250) (arbitrary unit, AU)/mL, anti-EBV > 200 (All > 200) (relative unit, RU)/mL, anti-HSV > 200 (152.75 to >200) RU/mL, anti-VZV > 5000 (All > 5000) IU/L, anti-measles > 5000 (All > 5000) IU/L, anti-mumps > 200 (156.5 to > 200) RU/mL, anti-rubella 209.8 IU/mL (192.7 to 238.5), and anti-Toxoplasma is 14.05 (12.3 to 16) IU/mL. There was not any immunoglobulin M (IgM) against HSV, VZV, mumps, measles, rubella, CMV, EBV, and Toxoplasma in the "Taiwan Blood Services Foundation" IVIG preparations. CONCLUSION There was high activity against T. gondii, VZV, EBV, measles, mumps, rubella, CMV, HSV-1, and HSV-2 in all IVIG batches. Further investigation is warranted to confirm the efficacy of IVIG from Taiwanese for congenital TORCH infections.
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Affiliation(s)
- Ya-Ling Chou
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Kao-Hsian Hsieh
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Cherng-Lih Perng
- Division of Clinical Pathology, Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Hueng-Chuen Fan
- Department of Pediatrics, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan, ROC
| | - Chiung-Hsi Tien
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chih-Chien Wang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Shyi-Jou Chen
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Fung-Wei Chang
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
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Polymyositis-Dermatomyositis and Interstitial Lung Disease in Pregnant Woman Successfully Treated with Cyclosporine and Tapered Steroid Therapy. Case Rep Rheumatol 2019; 2019:4914631. [PMID: 30984438 PMCID: PMC6432726 DOI: 10.1155/2019/4914631] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/05/2019] [Indexed: 12/03/2022] Open
Abstract
Polymyositis-dermatomyositis is extremely rare during pregnancy, and immunosuppressive therapy should be administered after carefully considering the effects on both the mother and fetus. Several reports have associated the disease activity with fetal prognosis, higher rates of eclampsia, preterm births, and fetal deaths. We report our experience with a patient who was diagnosed with polymyositis-dermatomyositis complicated by interstitial lung disease during pregnancy and was treated with a combination-immunosuppressant regimen. To the best of our knowledge, this is the first case wherein cyclosporine was used concomitantly with a steroid for the treatment of polymyositis diagnosed during pregnancy, with successful outcome of childbirth without any complications.
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Arese V, Murabito P, Ribero S, Panzone M, Tonella L, Fierro MT, Papini M, Quaglino P. Autoimmune connective tissue diseases and pregnancy. GIORN ITAL DERMAT V 2019; 154:263-276. [PMID: 30650958 DOI: 10.23736/s0392-0488.18.06252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autoimmune connective tissue-diseases are more frequent in women and deserve a multidisciplinary approach in which the dermatologist play a major role together with other physicians. Pregnancy in these patients has to be considered a high-risk situation, because of possible worsening of the mother's disease and increased morbility and mortality for the fetus; also, therapies have to be chosen carefully because some drugs cannot be used during pregnancy. For all these reasons, the decision to become pregnant needs to consider the type of disease, stage of disease, age and clinical condition, and requires a multidisciplinary approach. A correct counselling, a close monitoring, a specific approach based on the risks involved and the use of appropriate therapies are the keys to obtain optimal pregnancy outcomes.
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Affiliation(s)
- Veronica Arese
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Pierangela Murabito
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Simone Ribero
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Michele Panzone
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Luca Tonella
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Maria T Fierro
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Manuela Papini
- Department of Surgical and Biomedical Sciences, Dermatologic Clinic of Terni, University of Perugia, Perugia, Italy
| | - Pietro Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy -
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8
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Li Y, Meng L, Yuan Y, Meng L, Lin J, Bu B. Severe Recurrent Necrotizing Myopathy in Pregnancy: A Case Report. Front Neurol 2018; 9:1028. [PMID: 30546344 PMCID: PMC6279913 DOI: 10.3389/fneur.2018.01028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 11/14/2018] [Indexed: 12/13/2022] Open
Abstract
Pregnancy in patients with necrotizing autoimmune myopathy without identified antibodies is rarely reported. We report a case involving a 26-year-old woman with antibody-negative autoimmune necrotizing myopathy who experienced a relapse during pregnancy. Before pregnancy, the patient's myopathy symptoms and elevated serum creatine kinase levels had been successfully controlled with oral prednisone and tacrolimus for 1 year. However, she discontinued the therapy on her own accord, with the aim of conceiving. During pregnancy, she experienced a very severe relapse of muscle weakness and dyspnea and her creatine kinase level increased to >8,000 U/L. After she was treated with intravenous immunoglobulin, oral prednisone, and tacrolimus, she slowly recovered and delivered a healthy neonate. She continues to take oral tacrolimus (3 mg/day) and has remained symptom-free 2 years later.
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Affiliation(s)
- Yue Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingchao Meng
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yun Yuan
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Lijuan Meng
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Lin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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9
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Novel Therapeutic Options in Treatment of Idiopathic Inflammatory Myopathies. Curr Treat Options Neurol 2018; 20:37. [DOI: 10.1007/s11940-018-0521-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Anh-Tu Hoa S, Hudson M. Critical review of the role of intravenous immunoglobulins in idiopathic inflammatory myopathies. Semin Arthritis Rheum 2016; 46:488-508. [PMID: 27908534 DOI: 10.1016/j.semarthrit.2016.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this review was to summarize key findings from the literature concerning the therapeutic role of intravenous immunoglobulins (IVIg) in idiopathic inflammatory myopathies (IIM), dissecting the evidence according to disease subtype and treatment indication, and to review the evidence relating to the mechanism of action of IVIg in IIM to ascertain rationale for continued research. METHODS Medline (Ovid) and Pubmed databases were searched from inception to July 2016 using relevant keywords. Original and review articles were retrieved for full-text review. Bibliographies of selected articles were also hand-searched for additional references. Data were summarized qualitatively and in tabular form. RESULTS The efficacy of IVIg in IIM is supported by 3 randomized controlled trials, involving dermatomyositis and polymyositis subjects, in refractory, relapsed, or steroid-dependent disease, as well as part of first-line therapy in elderly dermatomyositis subjects. Other indications for IVIg are supported by uncontrolled evidence only. Limitations of studies include open, uncontrolled or retrospective study designs, small and selected samples, short-term follow-up and ad hoc outcome measures. Despite the limited evidence, there is strong biological plausibility for the role of IVIg in IIM. CONCLUSION Robust, controlled evidence to support the use of IVIg using validated outcome measures is urgently required to guide therapeutic decision-making and maximize outcomes in IIM.
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Affiliation(s)
- Sabrina Anh-Tu Hoa
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marie Hudson
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
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11
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A Case of New-Onset Dermatomyositis in the Second Trimester of Pregnancy: A Case Report and Review of the Literature. Case Rep Obstet Gynecol 2016; 2016:6430156. [PMID: 27478664 PMCID: PMC4958446 DOI: 10.1155/2016/6430156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 05/20/2016] [Accepted: 05/30/2016] [Indexed: 01/15/2023] Open
Abstract
Dermatomyositis (DM), a subtype of idiopathic inflammatory myopathies (IIMs), is characterized by skin rash, proximal muscle weakness, and inflammatory infiltrates in the muscle tissue. The peak incidence of the disease is at the age of 50–60 years, and only 14% of the patients with IIMs are estimated to present during reproductive years. Because of the limited pregnancy experience in patients with IIMs, little is known regarding the effects of DM on pregnancy or vice versa. We herein report a 40-year-old woman who developed DM in the second trimester of her pregnancy and did not respond to treatment with methylprednisolone. Her pregnancy was terminated at the 32nd week of gestation, due to preeclampsia and fetal distress. She delivered a healthy baby and improved rapidly after delivery. We have searched PubMed for relevant articles and reviewed previously published cases.
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12
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Wan J, Imadojemu S, Werth VP. Management of rheumatic and autoimmune blistering disease in pregnancy and postpartum. Clin Dermatol 2016; 34:344-52. [DOI: 10.1016/j.clindermatol.2016.02.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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13
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Needham M, Mastaglia FL. Immunotherapies for Immune-Mediated Myopathies: A Current Perspective. Neurotherapeutics 2016; 13:132-46. [PMID: 26586486 PMCID: PMC4720681 DOI: 10.1007/s13311-015-0394-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Until recently, the treatment of immune-mediated inflammatory myopathies has largely been empirical with glucocorticoids, steroid-sparing immunosuppressive drugs, and intravenous immunoglobulin. However, a proportion of patients are only partially responsive to these therapies, and there has been a need to consider alternative treatment approaches. In particular, patients with inclusion body myositis are resistant to conventional immunotherapies or show only a transient response, and remain a major challenge. With increasing recognition of the different subtypes of immune-mediated inflammatory myopathies, and improved understanding of their pathogenesis, more targeted treatments are now being trialled. The overall approach to treatment, and novel therapies targeting B cells, T cells, and specific cytokines are discussed in this review.
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Affiliation(s)
- Merrilee Needham
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, 6150, WA, Australia.
- Fiona Stanley Hospital, Murdoch, 6150, WA, Australia.
- West Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, 6009, WA, Australia.
| | - Frank L Mastaglia
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, 6150, WA, Australia
- West Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, 6009, WA, Australia
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14
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Ochiai M, Sato E, Tanaka E, Tochihara M, Shimizu Y, Osawa H, Sidara K, Sugimoto N, Hoshi D, Kawaguchi Y, Taniguchi, A, Yamanaka H. Successful delivery in a patient with clinically amyopathic dermatomyositis during pregnancy despite first-trimester acute exacerbation of interstitial lung disease. Mod Rheumatol 2015; 27:364-368. [DOI: 10.3109/14397595.2014.975906] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Moeko Ochiai
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Eri Sato
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Eiichi Tanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Mari Tochihara
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoko Shimizu
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hikota Osawa
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kumi Sidara
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoki Sugimoto
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Daisuke Hoshi
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Atsuo Taniguchi,
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
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15
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Abstract
A variety of neurologic diseases have cutaneous manifestations. These may precede, coincide with, or follow the neurologic findings. An array of autoimmune, genetic, and environmental factors play a role in expression and severity of the neurologic burden in these conditions. This chapter emphasizes congenital and genetic disorders, but we also discuss the pathophysiology and manifestation of various acquired neurocutaneous disorders with an emphasis Behcet's disease, dermatomyositis, Sjögren's syndrome, systemic lupus erythematosus, scleroderma, Parry-Romberg syndrome and Degos disease.
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Affiliation(s)
- Amre Nouh
- Department of Neurology, Hartford Hospital - University of Connecticut, Hartford CT, USA
| | - Jodi Speiser
- Section of Dermatopathology, Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA.
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16
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Cutaneous dermatomyositis: an updated review of treatment options and internal associations. Am J Clin Dermatol 2013; 14:291-313. [PMID: 23754636 DOI: 10.1007/s40257-013-0028-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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18
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Affiliation(s)
- Christina Lam
- Department of Dermatology; Brigham and Women's Hospital; Boston; Massachusetts
| | - Ruth Ann Vleugels
- Department of Dermatology; Brigham and Women's Hospital; Boston; Massachusetts
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Intravenous immunoglobulin therapy in adult patients with polymyositis/dermatomyositis: a systematic literature review. Clin Rheumatol 2012; 31:801-6. [DOI: 10.1007/s10067-012-1940-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/12/2011] [Accepted: 01/09/2012] [Indexed: 11/25/2022]
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Abstract
The inflammatory myopathies are a heterogeneous group of diseases including dermatomyositis, polymyositis, and inclusion body myositis. Few clinical trials have been conducted in myositis, making it difficult to provide clear recommendations on the treatment of these rare disorders. Although corticosteroids have not been tested in randomized controlled trials, the general expert consensus confirms their first-line use. However, in many patients, corticosteroid toxicity leads to significant disability, or these agents are ineffective, which then requires additional immunosuppression. Intravenous immunoglobulin is a reasonable short-term treatment with proven benefit in a controlled trial, but its long-term effectiveness remains unknown. The evidence for other immunosuppressive therapies has been derived mainly from case reports and open studies. These agents include methotrexate and/or azathioprine, followed by cyclosporine or tacrolimus (particularly for antisynthetase antibody-positive patients) and mycophenolate mofetil (for refractory rash). Newer therapies (eg, rituximab) are encouraging, but results from the largest randomized controlled trial studying this agent are soon to follow. The balance of evidence suggests that immunosuppressive drugs are effective in dermatomyositis and polymyositis, although randomized controlled trials are lacking.
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Ensom MHH, Stephenson MD. A two-center study on the pharmacokinetics of intravenous immunoglobulin before and during pregnancy in healthy women with poor obstetrical histories. Hum Reprod 2011; 26:2283-8. [PMID: 21771770 DOI: 10.1093/humrep/der227] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Despite the increasing use of intravenous immunoglobulin (IVIG) in obstetrics, information on its pharmacokinetics and optimal dosing during each trimester pregnancy is lacking. The aim of this study was to characterize IVIG pharmacokinetics in pregnant women with a history of idiopathic secondary recurrent miscarriage or obstetrical antiphospholipid syndrome and to make dosing recommendations by comparing serum immunoglobulin G (IgG) concentrations in women receiving IVIG to placebo controls, before and during pregnancy. METHODS Women enrolled in an IVIG trial for idiopathic secondary recurrent miscarriage (n = 25) or an IVIG study for obstetrical antiphospholipid syndrome (n = 10); 22 received IVIG 0.5-1.0 g/kg and 13 received the equivalent volume of saline, every 4 weeks from pre-pregnancy until 18-20 weeks of gestation, with dosing adjusted for her weight prior to each infusion. Serum IgG concentrations were measured by rate nephelometry before and 0.5 h, and 1, 2, 3 and 4 weeks following an infusion. Sampling was performed pre-pregnancy and in the first and second trimesters. RESULTS Area under the curve (AUC) did not differ significantly within the IVIG group between the three sampling periods. Estimated contributions of IVIG [calculated as mean AUC (IVIG group) minus mean AUC (control group)] were 4890.8 g h/l pre-pregnancy, 5591.4 g h/l first trimester and 4755.1 g h/l second trimester (P> 0.05, non-significant). For the IVIG 0.5 and 1.0 g/kg subgroups, the overall estimated contribution of exogenous IVIG was ~4000 and ~6400 g h/l, respectively. CONCLUSIONS With a weight-adjusted dosage of IVIG, drug exposure, based on AUC calculations, was maintained at the pre-pregnancy level. Therefore, we recommend a weight-adjusted dosage of IVIG during the first and second trimesters.
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Affiliation(s)
- Mary H H Ensom
- Pharmaceutical Sciences, Child and Family Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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22
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Okada R, Miyabe YS, Kasai S, Hashimoto K, Yamauchi S, Yoshikawa M, Sumori K, Nagasaka K. [Successful treatment of interstitial pneumonia and pneumomediastinum associated with polymyositis during pregnancy with a combination of cyclophosphamide and tacrolimus: A case report]. ACTA ACUST UNITED AC 2010; 33:142-8. [PMID: 20601834 DOI: 10.2177/jsci.33.142] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 30-year-old pregnant woman experienced mild dyspnea in April 2009. She complained of mild myalgia and was subsequently admitted to our hospital in June 2009 because of worsening dyspnea. Physical examination revealed fine crackles in the lower lung field, but no eruptions externally. Laboratory findings revealed elevated serum levels of myogenic enzymes (aldolase, 17.6 IU/l and myoglobin, 247.2 ng/ml) and positive titers for the anti-Jo-1 antibody and hypoxia (PaO(2), 79.4 Torr). The chest radiograph revealed a ground-glass opacity. The patient was diagnosed as interstitial pneumonia (IP) associated with polymyositis (PM) at 20 weeks of gestation. On July 9, we commenced the initial treatment-steroid pulse therapy with 60 mg/day of prednisolone and 3 mg/day of tacrolimus. We also induced abortion. The treatment of corticosteroids and tacrolimus was, however, ineffective even after increasing the tacrolimus dose to 6 mg/day. On July 30, she suddenly experienced chest pain along with severe dyspnea. Computed tomography revealed the presence of pneumomediastinum and deterioration of the IP. We added cyclophosphamide pulse therapy to the existing regimen ; this improved the disease course, reduced hypoxia, and improved radiographic findings. We believe that this is a rare case of IP with PM during pregnancy.
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Affiliation(s)
- Rika Okada
- Department of Rheumatology, Ome municipal general hospital
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23
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Intravenous immunoglobulin treatment for pregnancy-associated dermatomyositis. Rheumatol Int 2009; 31:113-5. [DOI: 10.1007/s00296-009-1166-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 09/20/2009] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW To review progress in areas pertinent to the development of better therapies for the idiopathic inflammatory myopathies. RECENT FINDINGS New classification criteria for the idiopathic inflammatory myopathies have been proposed in an effort to define disease subsets with more uniform prognoses and responses to therapy. Diseases that may mimic the idiopathic inflammatory myopathies can be differentiated more accurately with molecular testing and biochemical and immunohistochemical analysis of muscle tissue. Advances in our understanding of the pathogenesis of the idiopathic inflammatory myopathies have served to identify potential new therapeutic targets. International collaborative study groups have reached consensus on outcome measures and on the optimal design of clinical trials in the idiopathic inflammatory myopathies. Tumor necrosis factor-alpha antagonists, rituximab, and the calcineurin inhibitors are being used to treat the idiopathic inflammatory myopathies, but their efficacy has not yet been tested in randomized clinical trials. SUMMARY Future advances in the development of therapies for the idiopathic inflammatory myopathies have been enabled by recent progress in myositis classification, differential diagnosis, basic science, and clinical trial design. Preliminary studies suggest that calcineurin inhibitors, tumor necrosis factor antagonists, and rituximab may be effective treatments.
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Affiliation(s)
- Alan N Baer
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, University at Buffalo, SUNY, Erie County Medical Center, Buffalo, New York 14215, USA.
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26
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Ringel I, Zettl UK. Intravenous immunoglobulin therapy in neurological diseases during pregnancy. J Neurol 2007; 253 Suppl 5:V70-4. [PMID: 16998758 DOI: 10.1007/s00415-006-5012-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Immunological changes during pregnancy influence the course of neurological autoimmune diseases in different ways. In case of pregnancy immunomodulatory standard therapies such as interferon-beta, glatiramer acetate,monoclonal antibodies and cytostatics mostly should be discontinued. In those cases intravenous immunoglobulin (IVIg) therapy might be an alternative. In some diseases, contemporary publications describe positive therapeutic effects on the course of disease during or after pregnancy.
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Williams L, Chang PY, Park E, Gorson KC, Bayer-Zwirello L. Successful Treatment of Dermatomyositis During Pregnancy With Intravenous Immunoglobulin Monotherapy. Obstet Gynecol 2007; 109:561-3. [PMID: 17267895 DOI: 10.1097/01.aog.0000253244.45837.7c] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dermatomyositis is rare during pregnancy and, if untreated, is associated with poor fetal outcome. Corticosteroids are a standard treatment for dermatomyositis in pregnancy, but they have adverse effects. Intravenous immune globulin is an effective therapy for this condition and may have few adverse effects. CASE A young, white primigravida presented with dermatomyositis at 4 5/7 weeks of gestation (creatine kinase 2,762 units/L). Intravenous immune globulin was administered monthly at a dose of 1 g/(kg.d) for 2 consecutive days. The patient's symptoms resolved and no complications were experienced during therapy. At term, creatine kinase was 29 units/L and a healthy 3,657.5-g (8-lb, 1-oz) neonate was born. CONCLUSION Pregnant patients with dermatomyositis can be treated with intravenous immune globulin, resulting in good fetal outcome, thus avoiding the deleterious effects of corticosteroid therapy on pregnancy.
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Affiliation(s)
- Lloyd Williams
- Tufts University School of Medicine, Boston, MA 02135, USA
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Kerns MJJ, Graves JE, Smith DI, Heffernan MP. Off-Label Uses of Biologic Agents in Dermatology: A 2006 Update. ACTA ACUST UNITED AC 2006; 25:226-40. [PMID: 17174843 DOI: 10.1016/j.sder.2006.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include adalimumab, alefacept, efalizumab, etanercept, infliximab, IVIg, omalizumab, and rituximab. Most dermatologists are familiar with the indications of these medications that have been approved by the Food and Drug Administration; however, numerous off-label uses have evolved. To update the reader on more recent uses of the biologics for off-label dermatologic use, this article will emphasize more recent published data from 2005 through the date of submission in May 2006.
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Abstract
Dermatomyositis is one of the idiopathic inflammatory myopathies. It is characterized clinically by progressive symmetrical proximal muscle weakness and a characteristic rash. There are patients with rash who have little or no muscle disease. Although the process primarily attacks the skin and the muscles, it is a systemic disease with frequent manifestations in the gastrointestinal tract and pulmonary system. Dermatomyositis has been linked to internal malignancy in somewhere between 15% and 25%. Therapy for the muscle disease includes systemic corticosteroids with or without an immunosuppressive agent. Therapy of the skin disease begins with photoprotection and topical corticosteroids, but also includes the use of antimalarial agents and immunomodulatory therapies.
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Affiliation(s)
- Jeffrey P Callen
- Division of Dermatology, University of Louisville School of Medicine, KY 40202, USA.
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Aslanidis S, Pyrpasopoulou A, Kartali N, Zamboulis C. Successful treatment of refractory rash in paraneoplastic amyopathic dermatomyositis. Clin Rheumatol 2006; 26:1198-200. [PMID: 16779504 DOI: 10.1007/s10067-006-0337-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2006] [Accepted: 04/21/2006] [Indexed: 11/30/2022]
Abstract
Skin involvement in dermatomyositis does not always parallel muscle disease and can be the most active or severe component of the disease, failing to respond to therapeutic interventions that are adequate for myositis and other systemic involvement. This case refers to a resistant paraneoplastic amyopathic dermatomyositis rash which readily resolved with intravenous immunoglobulin (IVIG), practically in the form of monotherapy. This observation gains particular significance considering that IVIG is still regarded as a second-line therapeutic regimen in the treatment of dermatomyositis despite its prevalence in matters of safety.
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Affiliation(s)
- Spyros Aslanidis
- B' Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Konstantinoupoleos 49, Thessaloniki 54642, Greece.
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Lampropoulos CE, Hughes GRV, D' Cruz DP. Intravenous immunoglobulin in the treatment of resistant subacute cutaneous lupus erythematosus: a possible alternative. Clin Rheumatol 2006; 26:981-3. [PMID: 16670831 DOI: 10.1007/s10067-006-0222-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 01/18/2006] [Indexed: 10/24/2022]
Abstract
Subacute cutaneous lupus erythematosus (SCLE) is a common manifestation of systemic lupus erythematosus. In many cases it appears to be resistant to various systemic or topical treatments. Three cases of resistant SCLE with good response to intravenous immunoglobulin (IVIG) are described here suggesting that IVIG could be an alternative treatment in these patients.
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Affiliation(s)
- Christos E Lampropoulos
- The Louise Coote Lupus Unit, The Rayne Institute, St. Thomas' Hospital, 4 Lambeth Palace Road, London, SE1 7EH, UK
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Doria A, Iaccarino L, Ghirardello A, Arienti S, Zampieri S, Rampudda ME, Tincani A, Todesco S. Seltene autoimmune rheumatische Erkrankungen in der Schwangerschaft. Z Rheumatol 2006; 65:200, 202-6, 208. [PMID: 16670810 DOI: 10.1007/s00393-006-0059-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) affect young females during childbearing age. Over the last decades, improvements in survival as well as quality of life in patients affected with ARD have led to an increased number of pregnancies observed during the course of such diseases. Systemic lupus erythematosus (SLE) is the most frequently observed ARD during pregnancy, and the immunoendocrine changes occurring during pregnancy may influence the course of this disease. Pregnancy can also occur in patients with rare ARD, namely systemic sclerosis, polymyositis/dermatomyositis, systemic vasculitis including Wegener's granulomatosis, Churg-Strauss syndrome, polyarteritis nodosa, microscopic polyangiitis, Takayasu arteritis and Behçet disease. This review focuses on the complications during pregnancy caused by these rare ARD, and we briefly discuss the data published on these disorders. Some guidelines for the management of these conditions during pregnancy will also be provided. However, it is important to note that data on pregnancy outcome are very limited and, in the absence of prospective studies, most of the information derives from case reports and retrospective studies.
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Affiliation(s)
- A Doria
- Division of Rheumatology, Department of Medical and Surgical Sciences, University of Padova, Padova.
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Abstract
Many neuromuscular conditions occur more frequently during pregnancy and include carpal tunnel syndrome, Bell's palsy, lumbosacral radiculopathy, meralgia paresthetica, intercostal neuralgia, and other compression neuropathies. Preexisting or coincident neuromuscular diseases, including demyelinating polyneuropathies, inflammatory muscle disease, myasthenia gravis, and inherited nerve and muscle disease present specific problems during pregnancy. We review management of neuromuscular disorders during pregnancy, labor, delivery, and the early postpartum period.
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