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Grazzini S, Rizzo C, Conticini E, D'Alessandro R, La Barbera L, D'Alessandro M, Falsetti P, Bargagli E, Guggino G, Cantarini L, Frediani B. The role of bDMARDs in idiopathic inflammatory myopathies: A systematic literature review. Clin Exp Rheumatol 2023; 22:103264. [PMID: 36549353 DOI: 10.1016/j.autrev.2022.103264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Idiopathic inflammatory myopathies (IIM) are a group of different conditions typically affecting striate muscle, lung, joints, skin and gastrointestinal tract. Treatment typically relies on glucocorticoids and synthetic immunosuppressants, but the occurrence of refractory, difficult to treat, manifestations, may require more aggressive treatment, borrowed from other autoimmune diseases, including biologic disease modifying drugs (bDMARDs). In this regard, we conducted a systemic literature review in order to depict the current evidence about the use of bDMARDs in IIM. A total of 78 papers, published during the last 21 years, were retrieved. The majority of patients was treated with TNF-α inhibitors, whose effectiveness was assessed particularly in recalcitrant striate muscle, skin and joints involvement. Rituximab, whose evidence is supported by a large number of real-life studies and trials, seems to be an excellent option in case of ILD and anti-synthetase syndrome, while Tocilizumab, despite not meeting primary and secondary endpoints in a recently published clinical trial, proved its effectiveness in rapidly progressing ILD. Similarly, Abatacept, studied in a phase IIb clinical trial with conflicting evidence, was reported to be effective in some case reports of refractory dermatomyositis. Less data exist for anti-IL1 and anti-IL23 agents, which were employed particularly for inclusion body myositis and severe skin disease, respectively. This study provides an organ-focused assessment of bDMARDs in IIM, which display encouraging results in the treatment of refractory subsets of disease.
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Affiliation(s)
- Silvia Grazzini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Chiara Rizzo
- Rheumatology Section, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy.
| | - Roberto D'Alessandro
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Lidia La Barbera
- Rheumatology Section, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Miriana D'Alessandro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences and Neurosciences, University of Siena, Siena, Italy
| | - Paolo Falsetti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences and Neurosciences, University of Siena, Siena, Italy
| | - Giuliana Guggino
- Rheumatology Section, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Patil A, Lu J, Kassir M, Babaei M, Goldust M. Adult and juvenile dermatomyositis treatment. J Cosmet Dermatol 2023; 22:395-401. [PMID: 36065712 DOI: 10.1111/jocd.15363] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/17/2022] [Accepted: 09/02/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Dermatomyositis is a rare autoimmune inflammatory condition affecting skin and muscles. The disease can be seen in both adults and children. It can be associated with malignancy. Considering involvement of skin in the disease, many patients consult dermatologists for its treatment. Hence, knowledge about its presentation, complications, prognosis, and treatment is necessary. OBJECTIVE The objective of this review article is to provide comprehensive information about treatment of dermatomyositis. METHODS In this review article, we reviewed the published literature on adult and juvenile dermatomyositis to highlight the treatment. Articles published in peer-reviewed journals including reviews, clinical trials, case series, and case reports published in electronic database (MEDLINE/PubMed) through January 2021, cross references of respective articles and trials from clinicaltrials.gov were included for qualitative analysis of the literature. RESULTS Treatment options for dermatomyositis include traditional immunosuppressive agents and immunomodulatory therapy. High-dose corticosteroids represent the first line of treatment while other immunosuppressive agents are also used, either in combination with or as an alternative to corticosteroids, after initial treatment failure. Some biological agents have been used for the treatment of dermatomyositis with variable responses. CONCLUSION Although several treatment options are available, several questions remain unanswered about the optimal treatment of dermatomyositis.
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Affiliation(s)
- Anant Patil
- Department of Pharmacology, Dr. DY Patil Medical College, Navi Mumbai, India
| | - Jun Lu
- UConn Health Department of Dermatology, Farmington, Connecticut, USA
| | | | - Mahsa Babaei
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohamad Goldust
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Bitar C, Ninh T, Brag K, Foutouhi S, Radosta S, Meyers J, Baddoo M, Liu D, Stumpf B, Harms PW, Saba NS, Boh E. Apremilast in Recalcitrant Cutaneous Dermatomyositis: A Nonrandomized Controlled Trial. JAMA Dermatol 2022; 158:1357-1366. [PMID: 36197661 PMCID: PMC9535502 DOI: 10.1001/jamadermatol.2022.3917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/26/2022] [Indexed: 01/13/2023]
Abstract
Importance Cutaneous disease in dermatomyositis has no standardized treatment approach and so presents a challenging task for patients and clinicians. Objective To study the efficacy and safety of apremilast as an add-on therapy in patients with recalcitrant cutaneous dermatomyositis. Design, Setting, and Participants This phase 2a, open-label, single-arm nonrandomized controlled trial was conducted at a single center from June 2018 to June 2021. Participants were 8 patients with recalcitrant cutaneous dermatomyositis, defined by a cutaneous disease activity severity index (CDASI) score greater than 5 despite treatment with steroids, steroid-sparing agents, or both. Data were analyzed from June 2018 to June 2021. Interventions Apremilast 30 mg orally twice daily was added to ongoing treatment regimens. Main Outcomes and Measures The primary outcome was the overall response rate (ORR) at 3 months. Key secondary outcomes were the safety and toxicity of apremilast and the durability of response at 6 months. The CDASI, muscle score, dermatology life quality index (DLQI), and depression assessments were performed at baseline and regularly until month 7. Skin biopsies were performed at baseline and 3 months after apremilast (defined as 3 months into active apremilast therapy) and tested for gene expression profiling and immunohistochemical stains. Adverse events were assessed using the Common Terminology Criteria for Adverse Events version 5.0. Results Among 8 patients with recalcitrant cutaneous dermatomyositis (all women; mean [SD] age, 54 [15.9] years), a response was found at 3 months after apremilast among 7 patients (ORR, 87.5%). The mean (SD) decrease in CDASI was 12.9 (6.3) points at 3 months (P < .001). Apremilast was well tolerated, with no grade 3 or higher adverse events. Sequencing of RNA was performed on skin biopsies taken from 7 patients at baseline and at 3 months after therapy. Appropriate negative (ie, no primary antibody) and positive (ie, tonsil and spleen) controls were stained in parallel with each set of slides studied. Of 39 076 expressed genes, there were 195 whose expression changed 2-fold or more at P < .01 (123 downregulated and 72 upregulated genes). Gene set enrichment analysis identified 13 pathways in which apremilast was associated with downregulated expression, notably signal transducers and activators of transcription 1 (STAT1), STAT3, interleukin 4 (IL-4), IL-6, IL-12, IL-23, interferon γ (IFNγ), and tumor necrosis factor α (TNFα) pathways. In immunohistochemical staining, there was a mean (SD) decrease in phosphorylation levels STAT1 (22.3% [28.3%] positive cells) and STAT3 (13.4% [11.6%] positive cells) at the protein level, a downstream signaling pathway for the downregulated cytokines. Conclusions and Relevance These findings suggest that apremilast was a safe and efficacious add-on treatment in recalcitrant dermatomyositis, with an overall response rate of 87.5% and associations with downregulation of multiple inflammatory pathways. Trial Registration ClinicalTrials.gov Identifier: NCT03529955.
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Affiliation(s)
- Carole Bitar
- Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Thien Ninh
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Katherine Brag
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Stella Radosta
- Deming Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Jade Meyers
- School of Medicine, Tulane University, New Orleans, Louisiana
| | - Melody Baddoo
- Department of Pathology and Laboratory Medicine, Tulane University, New Orleans, Louisiana
- Tulane Cancer Center, Tulane University, New Orleans, Louisiana
| | - Delong Liu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Brittany Stumpf
- Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Paul W. Harms
- Department of Pathology, University of Michigan, Ann Arbor
| | - Nakhle S. Saba
- Section of Hematology and Medical Oncology, Deming Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Erin Boh
- Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana
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Chung MP, Paik JJ. Past, Present, and Future in Dermatomyositis Therapeutics. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2022; 8:71-90. [PMID: 38650607 PMCID: PMC11034924 DOI: 10.1007/s40674-022-00193-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 10/16/2022]
Abstract
Purpose of review This review highlights current and emerging pharmacologic therapies for the treatment of dermatomyositis (DM). Current clinical evidence, in addition to recently published and ongoing clinical trials for various drugs in development, are summarized in this review. Recent findings There has been significant progress in the research and development of potential treatments in DM. The FDA recently approved Octagam® 10% Immune Globulin Intravenous (IVIg) for the treatment of DM. Several drug targets are being explored as viable therapeutic options in phase 2 and phase 3 clinical trials; at the forefront of these are JAK inhibitors (tofacitinib and baricitinib) and T-cell co-stimulation blockers (i.e. abatacept). In addition, clinical trials are currently under way for therapeutics targeting novel molecular pathways, including immunoproteasome inhibitors, anti-B cell therapy, anti-interferon drugs, complement inhibitors, and phosphodiesterase-4 inhibitors. Summary With the large number of clinical trials, multiple novel therapeutics in development, and improved classification and outcome measures, the treatment landscape for DM will continue to rapidly evolve in the coming years as more options become available.
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Affiliation(s)
- Melody P. Chung
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julie J. Paik
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Elhage KG, Zhao R, Nakamura M. Advancements in the Treatment of Cutaneous Lupus Erythematosus and Dermatomyositis: A Review of the Literature. Clin Cosmet Investig Dermatol 2022; 15:1815-1831. [PMID: 36105749 PMCID: PMC9467686 DOI: 10.2147/ccid.s382628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022]
Abstract
Background Cutaneous lupus erythematosus (CLE) and dermatomyositis (DM) are autoimmune diseases that present with a wide variety of cutaneous manifestations. In both cases, first-line therapy includes topical corticosteroids. Patients may present with more widespread disease requiring systemic treatments, including corticosteroids, traditional immunosuppressants, or antimalarials. Due to their complex nature, both CLE and DM remain difficult to treat and continue to cause significant distress to patients. Objective To summarize the most recent literature on the safety and efficacy of novel treatment modalities for CLE and DM. Methods A literature search was conducted on PubMed using search terms “(dermatomyositis) AND (treatment)” and “(cutaneous lupus) AND (treatment)”. Additional search terms included specific names of biologic agents, phosphodiesterase inhibitors (apremilast), and JAK inhibitors. Results JAK inhibitors, PDE-4 inhibitors, and biologics have shown promise in reducing cutaneous symptoms of both CLE and DM, including reduction in SLE Disease Activity Index 2000 (SLEDAI-2K), Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI), British Isles Lupus Assessment Group (BILAG), Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI), and Disease Activity Score (DAS). Conclusion While there have been recent advancements in the treatment for CLE and DM, further research and clinical trials are required to better elucidate which therapy is best for individual patients.
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Affiliation(s)
- Kareem G Elhage
- University of California San Francisco, San Francisco, CA, USA
| | | | - Mio Nakamura
- Department of Dermatology, University of Michigan, Ann Arbor, MI, USA
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Connolly CM, Plomp L, Paik JJ, Allenbach Y. Possible future avenues for myositis therapeutics: DM, IMNM and IBM. Best Pract Res Clin Rheumatol 2022; 36:101762. [PMID: 35778272 DOI: 10.1016/j.berh.2022.101762] [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] [Indexed: 12/16/2022]
Abstract
Idiopathic inflammatory myopathies (IIMs) represent a heterogeneous group of systemic autoimmune diseases characterized by immune-mediated muscle injury. As insights into pathogenesis of IIM evolve, novel therapeutic strategies have become available to optimize outcomes. Herein, we summarize novel and emerging strategies in the management of dermatomyositis (DM), immunemediated necrotizing myopathy (IMNM), and inclusion body myositis (IBM).
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Affiliation(s)
- Caoilfhionn M Connolly
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lotta Plomp
- Department of Internal Medicine and Clinical Immunology, Pitié Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Julie J Paik
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, Pitié Salpêtrière Hospital, Sorbonne University, Paris, France.
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Chiapparoli I, Galluzzo C, Salvarani C, Pipitone N. A glance into the future of myositis therapy. Ther Adv Musculoskelet Dis 2022; 14:1759720X221100299. [PMID: 35634354 PMCID: PMC9136432 DOI: 10.1177/1759720x221100299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/26/2022] [Indexed: 12/24/2022] Open
Abstract
The idiopathic inflammatory myopathies are chronic diseases of the skeletal muscle that comprise various conditions, including dermatomyositis, polymyositis, immune-mediated necrotizing myopathy, and the antisynthetase syndrome. Although there are a number of distinguishing features, all these disorders are characterized by an immune and inflammatory response mainly directed against the muscle. Hence, therapy is geared toward curbing the autoimmune and inflammatory response. A quite wide range of medications are currently available to treat these disorders, but despite all therapeutic progress still a number of patients are unable to maintain a sustained remission. In this review article, we have marshaled a variety of potential therapeutic agents that may hold promise for the future treatment of the idiopathic inflammatory myopathies. It is to be expected that by increasing the therapeutic armamentarium with agents that have different mechanisms of action even challenging cases could be successfully managed, thus reducing disease burden and disability.
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Affiliation(s)
| | | | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Università di Modena e Reggio Emilia, Reggio Emilia, Italy
| | - Nicolò Pipitone
- Arcispedale Santa Maria Nuova, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
- Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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8
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Chong BF, Werth V. Cutaneous Lupus Erythematosus and Dermatomyositis: Utilizing Assessment Tools for Treatment Efficacy. J Invest Dermatol 2021; 142:936-943. [PMID: 34952717 DOI: 10.1016/j.jid.2021.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/06/2021] [Accepted: 09/17/2021] [Indexed: 12/19/2022]
Abstract
There have been important developments in defining cutaneous lupus erythematosus and dermatomyositis. The skin manifestations of these two diseases have a profound impact on QOL, with both emotional and symptomatic impacts that are important to address. The proliferation of potential therapeutic targets has made it important to make sure that these diseases are defined in a way that they can be included in translational and clinical studies of both localized and systemic forms of the diseases. There are now validated disease tools and QOL studies that are facilitating current and future scientific and therapeutic developments.
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Affiliation(s)
- Benjamin F Chong
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Victoria Werth
- Department of Dermatology, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.
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Konishi R, Tanaka R, Inoue S, Ichimura Y, Nomura T, Okiyama N. Evaluation of apremilast, an oral phosphodiesterase 4 inhibitor, for refractory cutaneous dermatomyositis: A phase 1b clinical trial. J Dermatol 2021; 49:118-123. [PMID: 34605053 DOI: 10.1111/1346-8138.16179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/28/2022]
Abstract
Dermatomyositis, an idiopathic inflammatory myopathy, is characterized by cutaneous itchy manifestations, which are frequently refractory and recurrent even after intensive immunosuppressive treatments. To evaluate the effectiveness and safety of apremilast, an oral phosphodiesterase 4 inhibitor, in treating skin-dominant dermatomyositis in which myositis and interstitial lung disease are absent or in remission, we performed this prospective, single-arm, interventional study. A total of five Japanese patients (one male and four females, median [range] age, 64 [37-71] years) with refractory dermatomyositis-associated cutaneous manifestations were recruited and treated with a 12-week course of oral apremilast. Among five enrolled patients, three experienced diarrhea with full-dose apremilast (30 mg twice daily), two of whom withdrew from the study and recovered quickly afterwards. A total of three evaluable female patients (median [range] age, 65 [64-71] years) received apremilast treatment for 12 weeks. A 39.4% reduction from baseline Cutaneous Dermatomyositis Disease Area and Severity Index total activity score, but not the damage score, at week 12 was observed in all three patients. Visual analog scale of itching, and quality of life by Dermatology Life Quality Index were slightly improved in one and two apremilast-treated patients, respectively. As apremilast was effective, with expected and recoverable digestive adverse events (diarrhea), in patients with refractory and recurrent dermatomyositis-associated cutaneous manifestations in this first phase Ib study, it can be suggested as a possible treatment when aggressive immunosuppressive therapies with high-dose systemic corticosteroid and/or immunosuppressive agents for other manifestations, myositis, and interstitial lung disease, are not required.
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Affiliation(s)
- Risa Konishi
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Ryota Tanaka
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Sae Inoue
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yuki Ichimura
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Toshifumi Nomura
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Naoko Okiyama
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Ll Wilkinson MG, Deakin CT, Papadopoulou C, Eleftheriou D, Wedderburn LR. JAK inhibitors: a potential treatment for JDM in the context of the role of interferon-driven pathology. Pediatr Rheumatol Online J 2021; 19:146. [PMID: 34563217 PMCID: PMC8466894 DOI: 10.1186/s12969-021-00637-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/28/2021] [Indexed: 12/29/2022] Open
Abstract
Juvenile Idiopathic Inflammatory Myopathies (IIM) are a group of rare diseases that are heterogeneous in terms of pathology that can include proximal muscle weakness, associated skin changes and systemic involvement. Despite options for treatment, many patients continue to suffer resistant disease and lasting side-effects. Advances in the understanding of the immunopathology and genetics underlying IIM may specify new therapeutic targets, particularly where conventional treatment has not achieved a clinical response. An upregulated type I interferon signature is strongly associated with disease and could be a prime target for developing more specific therapeutics. There are multiple components of the IFN pathway that could be targeted for blockade therapy.Downstream of the cytokine receptor complexes are the Janus kinase-signal transducers and activators of transcription (JAK-STAT) pathway, which consists of JAK1-3, TYK2, and STAT1-6. Therapeutic inhibitors have been developed to target components of this pathway. Promising results have been observed in case studies reporting the use of the JAK inhibitors, Baricitinib, Tofacitinib and Ruxolitinib in the treatment of refractory Juvenile Dermatomyositis (JDM). There is still the question of safety and efficacy for the use of JAK inhibitors in JDM that need to be addressed by clinical trials. Here we review the future for the use of JAK inhibitors as a treatment for JDM.
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Affiliation(s)
- Meredyth G Ll Wilkinson
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, University College London, London, UK.
- NIHR Biomedical Research Centre at GOSH, London, UK.
| | - Claire T Deakin
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, University College London, London, UK
- NIHR Biomedical Research Centre at GOSH, London, UK
| | - Charalampia Papadopoulou
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
- Rheumatology, Great Ormond Street Hospital, Great Ormond Street, London, UK
| | - Despina Eleftheriou
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
- Rheumatology, Great Ormond Street Hospital, Great Ormond Street, London, UK
| | - Lucy R Wedderburn
- Infection, Immunity and Inflammation Programme Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, University College London, London, UK
- NIHR Biomedical Research Centre at GOSH, London, UK
- Rheumatology, Great Ormond Street Hospital, Great Ormond Street, London, UK
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Kolla AM, Liu L, Shaw K, Shapiro J, Femia A, Lo Sicco K. A narrative review of therapies for scalp dermatomyositis. Dermatol Ther 2021; 34:e15138. [PMID: 34549494 DOI: 10.1111/dth.15138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/30/2022]
Abstract
Cutaneous involvement of the scalp is a common manifestation of dermatomyositis (DM), occurring in up to 82% of adults with DM. Scalp DM predominantly affects women and is characterized by dermatitis, alopecia, pruritus, and/or burning. While cutaneous DM negatively impacts quality-of-life, scalp symptoms in particular are often severe, debilitating, and recalcitrant to standard DM therapies. Currently, there is a paucity of guidelines to inform management of scalp symptoms in patients with cutaneous DM. In this narrative review, we summarize the treatments utilized to manage scalp DM and highlight potential areas for future research. We identified eight studies that reported on 27 treatments focused on cutaneous DM and described outcomes on scalp symptoms. A majority of the treatments were standard therapies for cutaneous DM and resulted in no or minimal improvement in scalp symptoms. Five therapies did result in complete resolution of scalp symptoms and were recommended as potential areas of future research. These included low-dose naltrexone and platelet-rich plasma, as well as two frequent and one less common therapy for cutaneous DM respectively: intravenous immunoglobulin, rituximab, and apremilast. Though the literature was not systematically assessed in this review, these findings illustrate not only that strategies for refractory scalp DM are lacking, but also that those demonstrating potential efficacy are limited by low levels of evidence. Additional studies, especially randomized controlled trials, are needed to better inform management of scalp DM.
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Affiliation(s)
- Avani M Kolla
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA
| | - Lynn Liu
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA
| | - Katharina Shaw
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA
| | - Jerry Shapiro
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA
| | - Alisa Femia
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA
| | - Kristen Lo Sicco
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA
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12
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Unger L. Therapieoptionen und outcome bei idiopathischen entzündlichen Muskelerkrankungen. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1423-7579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungDie idiopathischen entzündlichen Muskelerkrankungen (IIM) sind eine sehr heterogene Gruppe, die sich immer besser differenzieren lässt. Damit eröffnen sich mehr Möglichkeiten für gezieltere Therapien, die zum einen auf die Veränderung pathogenetischer Faktoren gerichtet sind. Zum anderen sollen sie Krankheitsaktivität vermindern, Muskelaufbau fördern, Organschäden verhindern und Lebensqualität verbessern.Die folgende Übersichtsarbeit fasst die vorhandenen Daten zu bereits angewandten Behandlungen in der Praxis zusammen und gibt einen Ausblick auf zukünftige Alternativen.Für die Polymyositis (PM) und Dermatomyositis (DM) sind Glukokortikoide weiter unverzichtbarer Therapiebestandteil. Eine frühe Kombination mit konventionellen DMARDs hat sich durchgesetzt. Die ProDerm- Studie stellt für die Immunglobulintherapie in der Praxis eine gute Basis dar. Rituximab (RTX) löst Cyclophosphamid (CYC) bei schweren Verlaufsformen immer mehr ab.Für Abatacept, Jak-Kinase-Hemmer, Apremilast, Sifalimumab und Lenabasum müssen vielversprechende erste Ergebnisse durch weiter Studien untermauert werden. Anspruchsvoll ist die Behandlung bei extramuskulärer Beteiligung. Von großem Interesse ist der zukünftige Stellenwert von Nintedanib bei der interstitiellen Lungenerkrankung im Rahmen einer Myositis (IIM-ILD).Die Therapie der Einschlusskörperchen- Myositis (IBM) ist immer noch eine große Herausforderung. Zahlreiche Studien haben bisher nicht überzeugend zu einer Besserung der Prognose führen können. Spätestens bei therapierefraktärem Verlauf sollte an eine Malignom- assoziierte Myositis gedacht werden. Gelegentlich verbirgt sich auch eine hereditäre Myopathie hinter einer, zum Beispiel durch einen Infekt oder Überlastung getriggerten, Myositis.Komplikationen im Verlauf, wie Dysphagie, Infektionen, Myokardbeteiligung stellen keine Seltenheit dar. Häufig besteht Multimorbidität. Eine interdisziplinäre Zusammenarbeit in einem kompetenten Team, in dem erfahrene Physio-, Ergo- und Psychotherapeuten fester Bestandteil sind, ist unabdingbar für eine erfolgreiche Begleitung dieser Patienten.
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Affiliation(s)
- Leonore Unger
- Städtisches Klinikum Dresden, I. Medizinische Klinik, Dresden, Deutschland
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Abstract
INTRODUCTION Currently, there are no proven drugs that are FDA approved for the treatment of dermatomyositis (DM), even though multiple clinical trials are ongoing to evaluate safety and efficacy of novel therapeutics in DM. The purpose of this review is to highlight the biological plausibility, existing clinical evidence as well as completed and ongoing clinical trials for various drugs in pipeline for development for use in dermatomyositis. AREAS COVERED The drugs with the strongest evidence have been included in this review with a focus on the mechanism of their action pertaining to the disease process, clinical studies including completed and ongoing trials. With better understanding of the underlying pathophysiologic process, there are new molecular targets that have been identified that can be targeted by these novel drugs, predominantly biologic drugs. EXPERT OPINION There are various drugs being evaluated in phase II/III clinical trials that hold promise in DM. At the forefront of these are immunoglobulin, Lenabasum, and Abatacept for which phase III clinical trials are ongoing. In addition, promising clinical studies are ongoing or reported for KZR-616, anti-B cell therapy, anti-interferon drugs, and Repository Corticotrophin Injection (RCI).
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Affiliation(s)
- Tanya Chandra
- Internal Medicine Residency Program, University of Connecticut , Farmington, CT, USA
| | - Rohit Aggarwal
- Department of Medicine, Rheumatology and Clinical Immunology, University of Pittsburgh , Pittsburgh, PA, USA
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van den Hoogen LL, van Laar JM. Targeted therapies in systemic sclerosis, myositis, antiphospholipid syndrome, and Sjögren's syndrome. Best Pract Res Clin Rheumatol 2020; 34:101485. [PMID: 32067925 DOI: 10.1016/j.berh.2020.101485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Targeted therapies using biological disease-modifying antirheumatic drugs (bDMARDs) and small molecule synthetic drugs have revolutionized rheumatological practice. Initially developed for the treatment of immune arthritis (rheumatoid arthritis, psoriatic arthritis, and spondylarthritis), both bDMARDs and small molecule synthetic drugs are now increasingly entering the space of connective tissue disease (CTD) treatment. Recent clinical trial data in systemic sclerosis (SSc) have been particularly encouraging with positive effects on outcomes having been observed with nintedanib preventing the decline of lung function in patients with SSc-related interstitial lung disease. Randomized trials targeting B-cells by rituximab in primary Sjogren's syndrome have led to mixed results. Novel strategies to target B-cells in primary Sjögren's syndrome including ianalumab and belimumab are underway and will hopefully result in clear treatment effects. Inflammatory idiopathic myositis (polymyositis (PM) and dermatomyositis (DM)) and antiphospholid syndrome are proving to be more difficult to tackle but are nonetheless the subject of ongoing studies. To what extent new compounds can replace more traditional immunosuppressive drugs remains to be determined, but if the experience in immune arthritis has taught us anything it is that combination therapy may be the way to go.
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Affiliation(s)
- Lucas L van den Hoogen
- Dept of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht University, the Netherlands.
| | - Jacob M van Laar
- Dept of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht University, the Netherlands.
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Abstract
PURPOSE OF THE REVIEW Dermatomyositis (DM) is an uncommon autoimmune disease that primarily affects the skin, muscle, and/or lungs, and remains a therapeutic challenge. We discuss recent studies evaluating efficacy of conventional treatments for clinically amyopathic DM (CADM), DM-associated interstitial lung (ILD) disease, and classic DM (CDM). We highlight several emerging new therapies with a focus on clinical trials, systematic reviews, and case series in the last 5 years. RECENT FINDINGS Recent studies report a significant number of patients remain refractory to antimalarials and require second- and third-line agents. Effective treatment for DM-associated ILD can vary based on patient specific antibodies. CDM requires oral glucocorticoids; recent studies have evaluated the benefits of adjunctive therapies including methotrexate and calcineurin inhibitors. New therapies target cell populations or cytokines thought to drive disease pathogenesis. Dermatomyositis is an autoimmune disease that remains challenging to treat. Many patients are refractory to conventional therapies, warranting the development and evaluation of new treatments.
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Patwardhan A, Spencer CH. Biologics in refractory myositis: experience in juvenile vs. adult myositis; part II: emerging biologic and other therapies on the horizon. Pediatr Rheumatol Online J 2019; 17:56. [PMID: 31429786 PMCID: PMC6702719 DOI: 10.1186/s12969-019-0361-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/08/2019] [Indexed: 12/12/2022] Open
Abstract
The idiopathic inflammatory myopathies (IIM) until recently have been considered a heterogeneous broad group of six autoimmune muscle diseases. Initially, autoantibodies in IIM (including JDM) and CD8+ T cell-induced cytotoxicity (PM and IBM) were the predominant recognized etiopathology mechanisms used to classify myopathies. In the early late 1990's to 2000's, evolving understanding of the molecules such as interleukin (IL), tumor necrosis factor (TNF), interferon (IFN), and other cytokines as well as differences in response to therapies, has led IIM researchers to look beyond previous disease mechanisms. For decades the overexpression of Th1- associated cytokines (TNF-α, IFN-γ and IL-12) in the areas of inflammation in skin and muscle in IIM pointed to Th1 as the primary pathway for inflammation in myositis.However, in the last decade overexpression and elevated level of Th17-associated cytokines (IL-17, IL-22, and IL-6) were identified in the blood and the inflamed muscles of myositis patients. We also do not know how Th1 and Th2 cytokines work differently in diverse hosts, in different concentrations, in different inflammatory milieus, and in the presence or absence of each other or other adhesion/co-stimulatory molecules such as NF-κB. Also, several autoantibodies to intracellular organelles have been identified in myositis.In this review, we will discuss the most recent advances in IIM research and how that might bring new biologic therapies to market in the next 5-15 years to assist in the care of our most difficult IIM and JDM patients.
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Affiliation(s)
- Anjali Patwardhan
- University of Missouri School of Medicine, 400 Keene Street, Columbia, MO, 65201, USA.
| | - Charles H. Spencer
- 0000 0004 1937 0407grid.410721.1University of Mississippi Medical Center, Batson Children’s Hospital, Rm 289, 2500 North State St, Jackson, MS 39216 USA
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