From the Guidelines
For a patient with dermatomyositis with scleroderma features whose main issues are inflammatory polyarthritis and skin changes, and who has already tried multiple immunosuppressive medications, I recommend adding abatacept (Orencia) to the current regimen. This recommendation is based on the most recent and highest quality study available, which suggests that in patients with peripheral arthritis and an inadequate response to at least one csDMARD, therapy with a bDMARD should be commenced 1. Abatacept can be administered as a 125 mg subcutaneous injection weekly or as an intravenous infusion based on weight (approximately 500-1000 mg) every 4 weeks. Some key points to consider when adding abatacept to the current regimen include:
- Mechanism of action: Abatacept works by blocking T-cell activation through CTLA-4 inhibition, which differs mechanistically from the patient's current therapies and may provide additional benefit for the inflammatory arthritis component.
- Baseline screening: Before starting abatacept, baseline screening should include tuberculosis testing, hepatitis B/C serology, and routine blood work.
- Efficacy and safety: Abatacept has shown efficacy in inflammatory arthritis resistant to other biologics and has a favorable safety profile when combined with other immunomodulators.
- Monitoring: Regular monitoring of disease activity through clinical assessment, muscle enzyme levels, and periodic imaging would be essential to evaluate treatment response. If abatacept is not effective after 3-4 months, alternative options could include JAK inhibitors like baricitinib or tofacitinib (different from previously tried Xeljanz), or consideration of intravenous immunoglobulin (IVIG) therapy, particularly if muscle involvement worsens, as suggested by the EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update 1.
From the Research
Treatment Options for Dermatomyositis with Scleroderma Features
The patient is currently experiencing inflammatory polyarthritis and skin changes, and is being treated with rituximab, plaquenil, prednisone, Cellcept, and actemra. Previously tried medications include methotrexate, xeljanz, leflunamide, and sulfasalazine.
Simplifying the Medication Regimen
To ensure the patient's medications are not creating more problems than they solve, it is essential to examine all medications being taken, whether prescription or not, and review each drug regimen in a systematic manner 2. Strategies to simplify complex medication regimens include consolidating dosing times, standardising routes of administration, using long-acting rather than shorter-acting formulations, and switching to combination products in place of single-ingredient products 3.
Biologics for Rheumatoid Arthritis
Abatacept, golimumab, and tocilizumab are effective in treating rheumatoid arthritis, particularly in patients who have not responded to methotrexate or tumor-necrosis-factor inhibitors 4. Tocilizumab has been shown to be effective in reducing disease activity and swollen joint count in patients who have not responded to rituximab 5.
Comparison of Biologics
A systematic review and network meta-analysis compared the efficacy of rituximab, abatacept, and tocilizumab in patients with rheumatoid arthritis refractory to methotrexate or TNF inhibitors, and found that abatacept was associated with a higher chance of achieving an ACR70 response compared to tocilizumab 6.
- Key points to consider:
- The patient's current medication regimen is complex and may benefit from simplification 2, 3.
- Biologics such as abatacept, golimumab, and tocilizumab may be effective in treating rheumatoid arthritis, particularly in patients who have not responded to other treatments 4, 5, 6.
- Tocilizumab may be a suitable option for patients who have not responded to rituximab 5.
- Abatacept may be associated with a higher chance of achieving an ACR70 response compared to tocilizumab 6.