Abstract
Dermatomyositis (DM) is an idiopathic inflammatory myopathy, which is potentially life threatening. To achieve disease remission, different therapeutic schedules may be required, with corticosteroid regimen being the first-line treatment. Recently the role of anti-TNF-α therapies as potential steroid sparing agents has been postulated. Herein, we performed a systematic review of the literature with special focus on anti-TNF-α therapies and DM. Different case reports, case series and one randomized controlled trial support the use of anti-TNF-α blocking agents, in particular etanercept and infliximab, as adjuvant therapy for DM and polymyositis (PM). The only available randomized controlled trial reported successful treatment with etanercept in 5/11 patients that weaned off prednisone in contrast to all five patients on the placebo group that failed the prednisone withdrawal schedule. There are approximately 42 other cases reported regarding the use of anti-TNF-α agents in patients affected by DM or PM. In 12 (28.6%) of those cases, a worsening of the disease was reported and in 13 patients (31%) the onset of severe adverse events forced the withdrawal of the drug, including two fatal cases. Another noteworthy fact regards the paradoxical onset of DM or PM in patients treated with TNF-α antagonists (18 cases reported), mainly for rheumatoid arthritis (15 cases). There is insufficient evidence from available reports to justify the routine use of anti-TNF-α agents in the management of patients affected by DM or PM. Further studies should be conducted before we can systematically use anti-TNF-α agents in the management of DM.
Financial and competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
• Dermatomyositis (DM) and polymyositis (PM) are idiopathic inflammatory myopathies, potentially life threatening and in many cases difficult to treat, because of relapses, scarce drug survival rates, complications and drug-related adverse events.
• To achieve disease-remission different therapeutical schedules may be required, being corticosteroids (per os or intravenously) the firstline worldwide-accepted treatment even in the absence of high quality evidence to support their use.
• A recently published Cochrane review-meta-analysis found that the only therapy that showed statistically significant superior efficacy against placebo was intravenous immunoglobulins.
• It has been postulated the role of anti-TNF-α therapies as potential steroid sparing agents. Different case reports, case series and one randomized controlled trial support the use of anti-TNF-α blocking agents, in particular etanercept and infliximab as adjuvant therapy for DM and PM.
• The only available randomized controlled trial reported a successful treatment in 5/11 patients that weaned off prednisone in contrast to all five patients on the placebo group that failed the prednisone withdrawal schedule. The skin disease worsening of 5/11 patients (45.45%) should alert us about the safety profile of such agents.
• There are approximately other 42 cases reported regarding the use of anti-TNF-α agents in patients affected by DM or PM. In 12 (28.6%) of those cases, a worsening of the disease was reported and in 13 patients (31%) the onset of severe adverse events forced the withdrawal of the drug, including two fatal cases.
• Another interesting fact regards the paradoxical onset of DM or PM in patients treated with TNF-α antagonists (18 cases reported), mainly for rheumatoid arthritis (15 cases).
• There is insufficient evidence from available reports to justify the routinely use of anti-TNF-α agents in the management of patients affected by DM or PM. Further studies should be conducted before we can systematically use the anti-TNF-α agents in the management of DM.
Notes
DM: Dermatomyositis; PM: Polymyositis.