Ibuprofen (Brufen) is NOT appropriate for treating inflammatory myopathies such as polymyositis or dermatomyositis
Ibuprofen has no role in the management of idiopathic inflammatory myopathies (polymyositis, dermatomyositis, immune-mediated necrotizing myopathy), which require immunosuppressive therapy with high-dose corticosteroids combined with steroid-sparing agents as first-line treatment. 1
Why NSAIDs Like Ibuprofen Are Inappropriate
Inflammatory Myopathies Require Immunosuppression, Not Symptomatic Treatment
The cornerstone of treatment for polymyositis and dermatomyositis is high-dose corticosteroids (prednisone ≈1 mg/kg/day or intravenous methylprednisolone) initiated concurrently with a steroid-sparing agent such as methotrexate, azathioprine, or mycophenolate mofetil from the outset. 1
These conditions are driven by autoimmune mechanisms—CD8+ cytotoxic T-cell invasion in polymyositis and complement-mediated microangiopathy in dermatomyositis—that will not respond to anti-inflammatory doses of NSAIDs. 2
Approximately 25% of patients are nonresponders to initial therapy and require escalation to intravenous immunoglobulin (2 g/kg over 2-5 days), rituximab, cyclophosphamide, or other immunosuppressants. 1, 3
When Ibuprofen IS Appropriate: Viral Myositis Only
Ibuprofen or acetaminophen is recommended for symptomatic pain relief in viral myositis, which is a benign, self-limited condition characterized by bilateral lower extremity myalgias following recent viral illness, with normal or only mildly elevated CK levels (<10× normal) and preserved muscle strength. 4
Viral myositis typically resolves within 3-7 days without immunosuppressive therapy, distinguishing it completely from autoimmune inflammatory myopathies that develop over weeks to months with progressive proximal muscle weakness. 2, 4
Critical Diagnostic Distinctions Before Considering Any Treatment
Features That Mandate Immunosuppression (NOT Ibuprofen)
Proximal muscle weakness developing over weeks to months—difficulty standing from a chair, climbing stairs, or lifting arms overhead—indicates inflammatory myopathy requiring immediate corticosteroid therapy. 1
Markedly elevated CK levels (often >10× upper limit of normal) with persistently elevated inflammatory markers (ESR, CRP) confirm immune-mediated myositis. 2, 1
Any cutaneous manifestations (heliotrope rash, Gottron papules, photosensitive erythema, periungual telangiectasias) indicate dermatomyositis and necessitate aggressive immunosuppression to prevent systemic complications including cardiac involvement and interstitial lung disease. 2, 1
Features Suggesting Benign Viral Myositis (Where Ibuprofen Is Appropriate)
Recent flu-like illness with bilateral calf pain or myalgias, normal or mildly elevated CK (<10× normal), absence of true muscle weakness (only pain-limited movement), and no rash. 4
Symptoms resolve spontaneously within one week without immunosuppressive intervention. 2, 4
Common Pitfalls to Avoid
Do not delay corticosteroid initiation in true inflammatory myopathy while attempting symptomatic management with NSAIDs; immune-mediated necrotizing myopathy can progress to rhabdomyolysis with myocardial involvement and fatal complications if not promptly treated. 5, 2
Do not assume that muscle pain with elevated CK is simply "myalgia"; polymyalgia rheumatica presents with severe myalgia and fatigue but has normal CK levels and no objective weakness on examination, whereas inflammatory myositis has both elevated CK and demonstrable proximal weakness. 5, 2
Do not overlook drug-induced myositis (statins, immune checkpoint inhibitors); persistent CK elevation >10× normal suggests necrotizing myopathy requiring corticosteroids and discontinuation of the offending agent, not symptomatic treatment with NSAIDs. 2
Specific Treatment Algorithm for Inflammatory Myopathies
Initial Therapy (First 4-6 Weeks)
- Start prednisone 1 mg/kg/day (or IV methylprednisolone 1 g daily × 3-5 days for severe disease) PLUS methotrexate 15-25 mg weekly OR azathioprine 2-3 mg/kg/day on day one. 1, 6, 7
Refractory Disease (No Response by 8-12 Weeks)
- Add intravenous immunoglobulin 2 g/kg divided over 2-5 days, then consider rituximab, mycophenolate mofetil, or tacrolimus depending on extramuscular manifestations. 1, 6, 8
Monitoring Response
- Serial CK measurements and manual muscle testing every 2-4 weeks guide treatment adjustments; begin corticosteroid taper only after satisfactory clinical response (improved strength, declining CK). 1