Article

Immunosuppressant and immunomodulatory treatment for dermatomyositis and polymyositis.

Academic Department of Rheumatology, GKT School of Medicine, King's College Hospital, Denmark Hill, London, UK, SE5 9RS.
Cochrane database of systematic reviews (Online) (Impact Factor: 5.94). 02/2005; DOI: 10.1002/14651858.CD003643.pub2
Source: PubMed

ABSTRACT Idiopathic inflammatory myopathies are chronic skeletal diseases with significant mortality and morbidity despite treatment by corticosteroids. Immunosuppressive agents and immunomodulatory therapy are used to improve disease control and reduce the long-term side effects of corticosteroids. While these treatments are used commonly in routine clinical practice, the optimal therapeutic regimen remains unclear.
To systematically review the evidence for the effectiveness of immunosuppressants and immunomodulatory treatments for dermatomyositis and polymyositis.
We searched the Cochrane Neuromuscular Disease Group trials register (searched February 2002 and updated in November 2003) and MEDLINE (January 1966 to December 2002). We checked bibliographies of identified trials and wrote to disease experts.
Randomised or quasi-randomised controlled trials including patients with probable or definite dermatomyositis and polymyositis as defined by the criteria of Bohan and Peter or definite, probable or mild/early by the criteria of Dalakas. Patients with inclusion body myositis should have been excluded by muscle biopsies. Any immunosuppressant or immunomodulatory treatment including corticosteroids, azathioprine, methotrexate, ciclosporin, chlorambucil, cyclophosphamide, intravenous immunoglobulin, interferon and plasma exchange was considered. Primary outcome was assessment of muscle strength after at least six months. Other outcomes were: change in disability, number of relapses and time to relapse, number of patients in remission and time-to-remission, cumulative corticosteroid dose and serious adverse effects.
Two authors (EC and JH) independently selected trials for inclusion in the review. Four authors independently assessed each study. Methodological criteria and the results of each study were recorded on data extraction forms.
Seven potentially relevant randomised controlled trials were identified. One trial was excluded. Three studies compared immunosuppressant with placebo control, one trial compared one immunosuppressant (methotrexate) with another (azathioprine), another trial compared ciclosporin A with methotrexate and the final trial compared intramuscular methotrexate with oral methotrexate plus azathioprine. The study comparing intravenous immunoglobulin with placebo concluded that the former was superior. Two randomised placebo-controlled trials assessing plasma exchange, leukapheresis and azathioprine produced negative results. The fourth study compared azathioprine with methotrexate and found azathioprine and methotrexate equally effective but methotrexate had a better side effect profile. The fifth study comparing ciclosporin A with methotrexate and the sixth study comparing intramuscular methotrexate with oral methotrexate plus azathioprine found no statistically significant differences between the treatment groups. Immunosuppressants are associated with significant side effects.
This systematic review highlights the lack of high quality randomised controlled trials that assess the efficacy and toxicity of immunosuppressants in inflammatory myositis.

1 Bookmark
 · 
107 Views
  • Arthritis & Rheumatology 02/2013; 65(2). · 7.48 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Polymyositis is one of a rare group of skeletal muscle diseases known as idiopathic inflammatory myopathies. The etiology is not fully understood, and its clinical presentation is often vague yet similar to more common neuromuscular diseases, making diagnosis difficult. A number of different tests are available to assist providers in making an accurate diagnosis. Once a diagnosis is made, there are a number of various treatment modalities available. Nurse practitioners must be familiar with treatment protocols and follow-up. The focus of this article is on polymyositis; its presentation, signs, and symptoms; the process of accurate diagnosis; and common treatment strategies.
    The Journal for Nurse Practitioners 09/2014;
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Polyvalent immunoglobin, derived from pooled human plasma, can be administered via the intravenous, subcutaneous or intramuscular route. Therapy is standard of care in the treatment of a number of immune-mediated pathologies across disciplines. By volume, the majority is used in neurology (~40%). In primary immunodeficiencies, therapy reconstitutes humoral immunity at replacement doses (0.4 - 0.6 g/ kg/month), decreasing infections, and is usually lifelong. However, high doses, usually 2 g/kg total dose over five days, are required for immunomodulation in autoimmune and inflammatory indications. A high-quality evidence base supports use in primary antibody failure, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, acute idiopathic thrombocytopenia, Kawasaki disease and immunobullous diseases. Low-quality evidence shows benefit in many other uncommon autoimmune and immunodeficient conditions. In South Africa, use of immunoglobulin therapy is restricted and, given the cost involved, will likely remain so. Therefore, the incremental benefit over other forms of immunosuppression, particularly corticosteroids, must be assessed carefully on a case-by-case basis. In most cases, therapy will be second-line or ‘rescue’ and motivation will be required. This short review aims to provide clinicians with the necessary understanding of the therapy, general considerations for use, and evidence base and quality thereof for well-established indications.
    South African Medical Journal 11/2014; 104(11):796.

Full-text

Download
2 Downloads
Available from
Jan 7, 2015