Polymyositis Medication

Updated: Nov 22, 2016
  • Author: Ramesh Pappu, MD, DPH, MBBS; Chief Editor: Herbert S Diamond, MD  more...
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Medication

Medication Summary

Therapy for polymyositis is based on immune suppression with steroids. Prednisone is the first-line treatment of choice for the disease. Immunosuppressive agents are indicated in patients who do not improve with steroids within a reasonable period (ie, 4 wk) or in whom adverse effects from corticosteroids develop. The role of newer agents, such as tumor necrosis factor (TNF) inhibitors and rituximab, remains unclear. However, the use of these agents in refractory cases has demonstrated some success. [22]

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Corticosteroids

Class Summary

These agents inhibit the inflammatory process via multiple mechanisms, including the inhibition of proinflammatory cytokine production, monocyte/macrophage function, and angiogenesis.

Prednisone

Prednisone is an anti-inflammatory and immunosuppressive agent used in the treatment of autoimmune disorders. It may decrease inflammation by reversing increased capillary permeability and suppressing neutrophilic activity. Prednisone also stabilizes the lysosomal membrane and suppresses lymphocytes, reducing cytokine and antibody production.

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Immunosuppressants

Class Summary

These agents may be of benefit in patients whose condition has not responded to steroids or in patients unable to tolerate prednisone.

Methotrexate (Rheumatrex, Trexall)

Methotrexate has an unknown mechanism of action in the treatment of chronic inflammatory diseases. It may affect immune function, including through inhibition of the production of proinflammatory cytokines. Methotrexate ameliorates symptoms of inflammation (eg, pain, swelling, stiffness). Adjust the dose gradually to attain a satisfactory response.

Azathioprine (Imuran, Azasan)

Azathioprine is a purine analog that inhibits the synthesis of deoxyribonucleic acid (DNA), RNA, and proteins. It may decrease the proliferation of immune cells, resulting in lower immunologic activity.

IV Immunoglobulin (Privigen, Hizentra, Octogam, Gammagard)

IVIG neutralizes circulating myelin antibodies through anti-idiotypic antibodies. It down-regulates proinflammatory cytokines, including interferon gamma; blocks Fc receptors on macrophages; suppresses helper T and B lymphocytes; and augments suppressor T lymphocytes. IVIG's exact mechanism of action in the treatment of polymyositis is unknown.

Chlorambucil (Leukeran)

Chlorambucil alkylates and cross-links strands of DNA, inhibiting DNA replication and RNA transcription.

Cyclophosphamide

Cyclophosphamide is chemically related to nitrogen mustards. As an alkylating agent, the mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with the growth of normal cells such as lymphocytes and neoplastic cells.

Cyclosporine (Sandimmune, Neoral, Gengraf)

Cyclosporine is a cyclic polypeptide that suppresses cell-mediated immune reactions such as delayed hypersensitivity and, to a lesser extent, humoral immunity, allograft rejection, experimental allergic encephalomyelitis, and graft versus host disease for a variety of organs. Cyclosporine selectively inhibits the transcription of interleukin 2, predominantly in helper lymphocytes.

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DMARDs, TNF Inhibitors

Class Summary

These agents may be used in refractory cases of polymyositis that have failed to respond to conventional therapy with steroids.

Etanercept (Enbrel)

Etanercept binds specifically to TNF and blocks its interaction with cell-surface TNF receptors, rendering TNF biologically inactive.

Infliximab (Remicade)

Infliximab binds to soluble and transmembranous forms of TNF-alpha, rendering TNF biologically inactive.

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Anti-CD20 Monoclonal Antibodies

Class Summary

Clinical trials with rituximab have shown encouraging results in patients who are refractory to first-line treatment.

Rituximab (Rituxan)

(Off-label) Rituximab is a humanized monoclonal antibody that binds to CD20 antigen, thereby inducing complement- or antibody-mediated cytolysis. Clinical trials in refractory polymyositis have shown improvement in patients who have failed corticosteroids and other immunosuppressive agents.

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