From the Guidelines
The management of autoimmune disorders and musculoskeletal injuries should prioritize a multidisciplinary approach, combining immunosuppressive treatments for autoimmune conditions with rest, physical therapy, and anti-inflammatory measures for tendon healing, as recommended by recent guidelines 1. The treatment of autoimmune conditions, such as rheumatoid arthritis or psoriatic arthritis, typically involves immunosuppressants like methotrexate (starting at 7.5-15mg weekly) and corticosteroids (prednisone 5-60mg daily depending on severity), as well as biologics like TNF inhibitors (adalimumab, etanercept) 1. For tendon healing, the RICE protocol (Rest, Ice, Compression, Elevation) is recommended for acute injuries, followed by physical therapy focusing on eccentric strengthening exercises after the acute phase, typically 2-4 weeks post-injury 1. Key considerations include:
- The use of non-steroidal anti-inflammatory drugs like ibuprofen (400-800mg three times daily) or naproxen (250-500mg twice daily) for short-term pain and inflammation management
- Nutritional support with adequate protein (1.2-1.6g/kg body weight daily), vitamin C (500mg daily), and collagen supplements (10-15g daily) to enhance healing
- The importance of controlling autoimmune activity to create a favorable healing environment for musculoskeletal recovery, as excessive inflammation can impair normal tissue healing 1. A shared decision-making process between patients, oncologists, and rheumatologists is crucial for managing rheumatic and musculoskeletal immune-related adverse events, as recommended by the EULAR points to consider for the diagnosis and management of rheumatic immune-related adverse events due to cancer immunotherapy with checkpoint inhibitors 1.
From the FDA Drug Label
In Study JIA-I, 10% of patients treated with HUMIRA who had negative baseline anti-dsDNA antibodies developed positive titers after 48 weeks of treatment. No patient developed clinical signs of autoimmunity during the clinical trial. Approximately 15% of patients treated with HUMIRA developed mild-to-moderate elevations of creatine phosphokinase (CPK) in Study JIA-I Elevations exceeding 5 times the upper limit of normal were observed in several patients. CPK concentrations decreased or returned to normal in all patients. In the rheumatoid arthritis controlled trials, 12% of patients treated with HUMIRA and 7% of placebo-treated patients that had negative baseline ANA titers developed positive titers at week 24. Two patients out of 3046 treated with HUMIRA developed clinical signs suggestive of new-onset lupus-like syndrome.
The effect of adalimumab on autoimmune disorders is that it may induce the development of autoantibodies, such as ANA and anti-dsDNA antibodies, in some patients. However, the clinical significance of this is unclear, as not all patients who developed autoantibodies went on to develop clinical signs of autoimmunity. Regarding the healing of musculoskeletal injuries, the data suggests that adalimumab may not have a significant impact on the healing process, as elevations in CPK were observed in some patients, but these elevations were generally mild and resolved on their own. However, the evidence is limited, and no firm conclusions can be drawn. 2 2
From the Research
Autoimmune Disorders and Musculoskeletal Injuries
- The treatment of autoimmune diseases, such as rheumatoid arthritis, involves various strategies including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease-modifying anti-inflammatory drugs (DMARDs) 3.
- Autoimmune connective tissue diseases (ACTDs) have been found to increase the risk of rotator cuff repair surgery, with an adjusted hazard ratio (aHR) of 1.97 compared to the control cohort 4.
- The use of non-steroidal anti-inflammatory drugs (NSAIDs) in ACTD patients has been associated with a higher risk of rotator cuff surgery, with an aHR of 3.13 compared to the controls 4.
- Tissue-specific immune modulation using tolerogenic dendritic cells pulsed with autoantigen may be a potential approach for inducing tolerance in autoimmune diseases such as rheumatoid arthritis 5.
Healing of Musculoskeletal Injuries
- Adult tendon tissue has a limited regenerative capacity, and the natural repair process often results in fibrotic scar tissue with inferior mechanical properties 6.
- Biomaterials-based approaches have been explored to improve tendon repair, including the use of biodegradable scaffolds, bioactive factor delivery, and cell-based therapies 6.
- A comprehensive approach that balances regulated inflammation and tenogenesis may be necessary to improve the healing outcome of tendon injuries, and biomaterials-based strategies may play a key role in achieving this balance 6.
- The treatment of musculoskeletal injuries, such as rotator cuff tears, may be influenced by the presence of autoimmune connective tissue diseases, and the use of anti-inflammatory medications may impact the risk of surgical intervention 4.