From the Guidelines
For dermatomyositis with scleroderma features and persistent inflammatory polyarthritis despite current therapy with rituximab, plaquenil, and CellCept, the next best treatment option would be adding methotrexate, as it has shown promise in treating skin involvement in systemic sclerosis, with a between-group difference of approximately 5 points in mRSS in favor of methotrexate, compared with placebo 1. Methotrexate is typically administered as 15-25 mg per week, and its effectiveness in treating inflammatory polyarthritis is well-established. Key considerations for treatment include:
- Monitoring for potential side effects, such as liver toxicity and bone marrow suppression
- Regular blood work every 4-8 weeks to monitor complete blood count, liver function, and kidney function
- Screening for tuberculosis, hepatitis B and C, and updating vaccinations before initiating methotrexate Other viable options, such as cyclophosphamide, tocilizumab, or rituximab, may also be considered, but methotrexate is a more commonly used first-line treatment for skin manifestations in patients with dcSSc 1. It is essential to weigh the benefits and risks of each treatment option and consider the individual patient's needs and medical history when making a decision. In general, treatment should be aimed at reaching a target of sustained remission or low disease activity, and monitoring should be frequent in active disease, with adjustments to therapy as needed 1.
From the Research
Treatment Options for Dermatomyositis with Scleroderma Features
The patient is currently experiencing inflammatory polyarthritis, and is being treated with rituximab, plaquenil, and Cellcept. Considering the current treatment regimen, the next best option for treatment could be:
- Adding a steroid-sparing immunosuppressive agent, such as methotrexate or azathioprine, to reduce the dose of glucocorticoids and minimize their adverse effects 2, 3
- Using biologics, such as abatacept, which has shown promise in treating inflammatory myopathies 3
- Considering multi-target treatment with glucocorticoids and several steroid-sparing immunosuppressive agents, which has been effective in refractory cases 3
Management of Inflammatory Polyarthritis
For the management of inflammatory polyarthritis, the following options could be considered:
- Adding a disease-modifying antirheumatic drug (DMARD), such as methotrexate or sulfasalazine, to the current treatment regimen 2, 3
- Using biologics, such as rituximab, which has already been initiated, or other biologics like abatacept or tocilizumab 3
- Considering the use of Janus kinase inhibitors, which are a new class of drugs that have shown promise in treating inflammatory arthritis 4
Monitoring and Evaluation
Regular monitoring and evaluation of the patient's condition is crucial to assess the effectiveness of the treatment and to adjust the treatment regimen as needed. This includes: