Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America

Abstract

BackgroundThe prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960’s with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011–2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA).MethodsThe JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011–2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013–2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting.ResultsOne hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups.ConclusionsOur CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future.Significance and InnovationsThis is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years.This experience with biologic thera...

Juvenile dermatomyositis: Latest advances

“…There has been an increasing focus on early aggressive treatment, with prompt stepwise use of medications to achieve timely remission and reduce risk of complications from disease and long-term drug toxicity (26). A recent survey in North America revealed clinicians are selecting various biologics for recalcitrant disease (20) including rituximab (most popular), abatacept, TNFα blockade, and tocilizumab. A randomised placebo phase design trial of rituximab in adults and children with dermatomyositis failed to reach primary or secondary endpoints, but the overall response rate, steroid-sparing effect and re-treatment response suggested that rituximab is efficacious for both muscle and skin disease (27, 28).…”

Retrospective analysis of infliximab and adalimumab treatment in a large cohort of juvenile dermatomyositis patients

“…Biologic drugs have been used off-label since 2000 for JDM and other inflammatory myositis diseases with encouraging results [19]. High levels of TNF-α have been reported in JDM patients with a long disease course suggesting that it may play a significant role in refractory disease [7].…”

“…High levels of TNF-α have been reported in JDM patients with a long disease course suggesting that it may play a significant role in refractory disease [7]. A recent study published by Spencer et al [19], the results of a survey on CARRA members' experience of using biologics in JDM, showed that survey responders considered that use of biologics significantly reduced complications in JDM (such as calcinosis, muscle atrophy, lipodystrophy) and were a logical therapeutic step after failure of corticosteroid and other immunosuppressive therapy, in JDM patients with resistant disease.…”

Erythematous scaling lesions of the face, dorsal fingers, elbows, and knees together with symmetrical muscle weakness in a child

“…Due to a relatively safe profile, treatment options with TNF‐α antagonists such as infliximab or etanercept may be used in children with treatment‐resistant dermatomyositis …”