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Ibrahim F, Choy E, Gordon P, Doré CJ, Hakim A, Kitas G, Isenberg D, Griffiths B, Lecky B, Chakravarty K, Winer J, Danko K, Cooper RG, White-Alao B, Scott DL. Second-line agents in myositis: 1-year factorial trial of additional immunosuppression in patients who have partially responded to steroids. Rheumatology (Oxford) 2014; 54:1050-5. [PMID: 25433040 PMCID: PMC4476843 DOI: 10.1093/rheumatology/keu442] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Ciclosporin and MTX are used in idiopathic inflammatory myopathies (DM and PM) when patients incompletely respond to glucocorticoids. Their effectiveness is unproved in randomized controlled trials (RCTs). We evaluated their benefits in a placebo-controlled factorial RCT. METHODS A 56-week multicentre factorial-design double-blind placebo-controlled RCT compared steroids alone, MTX (15-25 mg weekly) plus steroids, ciclosporin (1-5 mg/kg/day) plus steroids and all three treatments. It enrolled adults with myositis (by Bohan and Peter criteria) with active disease receiving corticosteroids. RESULTS A total of 359 patients were screened and 58 randomized. Of the latter, 37 patients completed 12 months of treatment, 7 were lost to follow-up and 14 discontinued treatment. Patients completing 12 months of treatment showed significant improvement (P < 0.001 on paired t-tests) in manual muscle testing (14% change), walking time (22% change) and function (9% change). Intention to treat and completer analyses indicated that ciclosporin monotherapy, MTX monotherapy and ciclosporin/MTX combination therapy showed no significant treatment effects in comparison with placebo. CONCLUSION Neither MTX nor ciclosporin (by themselves or in combination) improved clinical features in myositis patients who had incompletely responded to glucocorticoids. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number Register; http://www.controlled-trials.com/; ISRCTN40085050.
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Affiliation(s)
- Fowzia Ibrahim
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Ernest Choy
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Patrick Gordon
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Caroline J Doré
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Alan Hakim
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - George Kitas
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - David Isenberg
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Bridget Griffiths
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Bryan Lecky
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Kuntal Chakravarty
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - John Winer
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Katalin Danko
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Robert G Cooper
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Beverley White-Alao
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - David L Scott
- Department of Rheumatology, King's College London, London, Cardiff Institute of Infection & Immunity, Cardiff University School of Medicine, Cardiff, MRC Clinical Trials Unit, Department of Rheumatology, Whipps Cross University Hospital, London, Rheumatology, Russells Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, Dudley, Department of Rheumatology, University College London Hospitals, London, Musculoskeletal Unit, Freeman Hospital, Newcastle, Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, Department of Rheumatology, Queen's Hospital, Romford, Department of Neurology, The Queen Elizabeth Hospital Neuroscience Centre, Birmingham, UK, Department of Internal Medicine, Medical University of Debrecen, Debrecen, Hungary and Rheumatic Diseases Centre, Salford Royal NHS Foundation Trust, Manchester, UK
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