Discussion
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]. 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.
In our study, those who received infliximab and who switched from infliximab to adalimumab showed improvement in terms of global disease and improvement compared to their own baseline, but we cannot exclude the effects of other concomitant medications due to the lack of a control group. Muscle and skin disease appeared to reduce with infliximab treatment, with improvement in CMAS and MMT8 and the modified DAS. Importantly, we observed a reduction in steroid dose after 12 months of treatment with anti-TNF, which may suggest a possible steroid-sparing effect.
Major limitations of this study include missing data (commonly encountered in multi-site cohort studies) and the lack of a control group. We recognize that it is a limitation of our study that controls were not able to be included in the analysis. We have previously used observational data to model efficacy of cyclophosphamide, another second-line treatment for JDM, using the MSM method which allowed us to compare disease activity in patients treated with the drug to those who were not treated with the drug [
20]. However, this method was not feasible in this study because we included two different drugs (infliximab and adalimumab) and treatment durations were heterogeneous. Obtaining evidence for second-line treatments in this rare disease is challenging, and there is an important role for observational studies and large case series like this study. Therefore, we cannot exclude effects of concomitant medications etc.
Infliximab was switched to adalimumab in 15 patients (25%). Ten (66.7%) of the switches were due to incomplete control of disease, mainly due to lack of skin disease control. The remaining causes for switching were adverse effects and patient preference.
Calcinosis remains a significant source of morbidity for many JDM patients, yet it is poorly understood and lacks uniform treatment approaches compared to other aspects of JDM. A recent study published by the CARRA group [
21] emphasizes the inconsistency in the published literature regarding therapeutic effectiveness. The authors suggest that this can be explained by the relative inexperience of physicians and the multitude of different treatments and treatment scenarios [
21]. In our study, there was a reduction in the number and/or size of calcinotic lesions in 54% of the patients that were on infliximab/adalimumab and calcinosis completely resolved in 29% of them, although we cannot attribute these effects to anti-TNF treatment alone. It was also noted that the reduction in number and size of calcinosis needed nearly 2 years on anti-TNF treatment. Although we had a patient that showed evident reduction on calcinosis lesions only after 3 months on anti-TNF treatment, the majority needed a much longer time and in one case it was necessary to continue 10 years of anti-TNF treatment until the calcinosis completely resolved. This highlights that an immediate improvement on the calcinosis should not be expected, and the anti-TNF treatment should not be stopped if an immediate improvement is not seen.
Regarding safety, the majority of the adverse events were mild to moderate and mostly due to infections causes. However, we had 12 serious adverse events, mostly (
n = 9) related with allergic reactions to infliximab. Administration of infliximab is associated with a well-recognized risk of infusion-related adverse events. The exact aetiology and pathogenesis of those infusion reactions are often unclear, and findings regarding their allergic/immune nature are inconsistent [
22]. Overall the anti-TNF drugs seemed to be well-tolerated in our population with an incidence of 5.7 serious adverse reactions by 100 patient-years, which is consistent with the literature on adult patients [
23]. Importantly, the majority of patients had no adverse effects and tolerated the infliximab/adalimumab well, and in the context of patients needing long-term treatment, this could be of benefit.
This study is one of the largest to describe the use of infliximab and adalimumab in a large national cohort of JDM patients. Further clinical studies are required to assess the efficacy of anti-TNF treatment in JDM, controlling for the effects of other DMARDS, and to ascertain the optimum timing for treatment initiation and cessation. Stratified analysis by autoantibody subgroups could be addressed in future studies with greater numbers.
Acknowledgements
We would like to thank all patients and their families who have contributed to the JDCBS. We also thank all members of the JDRG who contribute to the JDCBS. The JDRG members were as follows:
Dr. Kate Armon, Mr. Joe Ellis-Gage, Ms. Holly Roper, Ms. Vanja Briggs and Ms. Joanna Watts (Norfolk and Norwich University Hospitals), Dr. Liza McCann, Mr. Ian Roberts, Dr. Eileen Baildam, Ms. Louise Hanna, Ms. Olivia Lloyd, Susan Wadeson and Michelle Andrews (The Royal Liverpool Children’s Hospital, Alder Hey, Liverpool), Dr. Phil Riley, Ms. Ann McGovern, Verna Cuthbert (Royal Manchester Children’s Hospital, Manchester), Dr. Clive Ryder, Mrs. Janis Scott, Mrs. Beverley Thomas, Professor Taunton Southwood, Dr. Eslam Al-Abadi and Ruth Howman (Birmingham Children’s Hospital, Birmingham), Dr. Sue Wyatt, Mrs. Gillian Jackson, Dr. Mark Wood, Dr. Tania Amin, Dr. Vanessa VanRooyen and Ms. Deborah Burton, Louise Turner & Sarah Hanson (Leeds General Infirmary, Leeds), Dr. Joyce Davidson, Dr. Janet Gardner-Medwin, Dr. Neil Martin, Ms. Sue Ferguson, Ms. Liz Waxman and Mr. Michael Browne, Ms. Roisin Boyle, Ms. Emily Blyth (The Royal Hospital for Sick Children, Yorkhill, Glasgow), Dr. Mark Friswell, Professor Helen Foster, Mrs. Alison Swift, Dr. Sharmila Jandial, Ms. Vicky Stevenson, Ms. Debbie Wade, Dr. Ethan Sen, Dr. Eve Smith, Ms. Lisa Qiao, Mr. Stuart Watson and Ms. Claire Duong (Great North Children’s Hospital, Newcastle), Dr. Helen Venning, Dr. Rangaraj Satyapal, Mrs. Elizabeth Stretton, Ms. Mary Jordan, Dr. Ellen Mosley, Ms. Anna Frost, Ms. Lindsay Crate, Dr. Kishore Warrier, Stefanie Stafford, Kelly Sandhu & Tracey Dandy (Queens Medical Centre, Nottingham), Professor Lucy Wedderburn, Dr. Clarissa Pilkington, Dr. Nathan Hasson, Dr. Muthana Al-Obadi, Dr. Giulia Varnier, Dr. Sandrine Lacassagne, Mrs. Sue Maillard, Mrs. Lauren Stone, Ms. Elizabeth Halkon, Ms. Virginia Brown, Ms. Audrey Juggins, Dr. Sally Smith, Mrs. Sian Lunt, Ms. Elli Enayat, Mrs. Hemlata Varsani, Miss Laura Kassoumeri, Miss Laura Beard, Miss Katie Arnold, Mrs. Yvonne Glackin, Ms. Stephanie Simou, Dr. Beverley Almeida, Dr. Kiran Nistala, Dr. Raquel Marques, Dr. Claire Deakin, Dr. Parichat Khaosut, Ms. Stefanie Dowle, Dr. Charalampia Papadopoulou, Dr. Shireena Yasin, Dr. Christina Boros, Dr. Meredyth Wilkinson, Dr. Chris Piper, Mrs. Cerise Johnson-Moore, Ms. Lucy Marshall, Ms. Kathryn O’Brien, Ms. Emily Robinson (Great Ormond Street Hospital, London), Dr. Kevin Murray (Princess Margaret Hospital, Perth, Western Australia) Dr. Coziana Ciurtin, Dr. John Ioannou, Mrs. Caitlin Clifford and Ms. Linda Suffield (University College London Hospital, London) Ms. Helen Lee, Ms. Sam Leach, Ms. Helen Smith, Dr. Anne-Marie McMahon, Ms. Heather Chisem, Jeanette Hall, Ruth Kingshott and Maxine Mutten (Sheffield’s Children’s Hospital, Sheffield); Dr. Nick Wilkinson, Ms. Emma Inness, Ms. Eunice Kendall, Mr. David Mayers, Ruth Etherton, Danielle Miller and Dr. Kathryn Bailey (Oxford University Hospitals, Oxford); Dr. Jacqui Clinch, Ms. Natalie Fineman, Ms. Helen Pluess-Hall and Suzanne Sketchley (Bristol Royal Hospital for Children, Bristol); Dr. Joyce Davidson, Margaret Connon and Ms. Lindsay Vallance (Royal Aberdeen Children’s Hospital); Dr. Kirsty Haslam, Charlene Bass-Woodcock, Trudy Booth and Ms. Louise Akeroyd (Bradford Teaching Hospitals); Dr. Alice Leahy, Amy Collier, Rebecca Cutts, Emma Macleod, Dr. Hans De Graaf, Dr. Brian Davidson, Sarah Hartfree, Danny Pratt, Elizabeth Fofana and Lorena Caruana (University Hospital Southampton) and all the Children, Young people and their families who have contributed to this research.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.