Year: 2022
Type: article
Study design: Observational Study
Abstract: Dear Editor, Treatment of dermatomyositis (DM) typically follows a stepwise sequence starting with methotrexate (MTX) or mycophenolate mofetil (MMF) after inadequate antimalarial response.1 However, data are scarce regarding the effectiveness of MTX and MMF. A cohort of 24 patients with current skin‐predominant DM was identified from a prospective database at the University of Pennsylvania Perelman School of Medicine. Patients included in the cohort took MTX or MMF and had at least two study visits within a retrospective observation period from October 2008 to February 2021. The Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI), a validated disease scoring tool,2 was used to assess severity and outcomes. Patients with mild disease activity, defined as a CDASI activity (CDASI‐A) score < 14 (maximum subscore of 100), were excluded as were any patients on medications used to treat DM other than MTX or MMF, with the exception of chronic antimalarials or topical medications. For both MMF (n = 13) and MTX (n = 11), there was no baseline difference in CDASI‐A scores at treatment initiation. There was no significant difference in the degree of improvement on either medication, with a mean difference in daily CDASI‐A change between MTX and MMF of −0·0028 ± 0·0024 (P = 0·24) using a mixed linear effects model. For MTX, the median percentage change in CDASI‐A between the first and last study visit was −74%. For MMF, the median percentage change was −76%. A decrease of 40% or greater in the CDASI‐A score has previously been associated with a meaningful change in quality of life.3 When ‘responders’ were defined as having a ≥ 40% improvement in their CDASI‐A score between the first and second observations (Figure 1), 27% of the patients taking MTX were responders while 54% of patients taking MMF were responders. The range of time varied between the first and second visits, with 50% of patients having a second study visit within 150 days. By last follow‐up, 55% of patients taking MTX were considered responders and 77% of patients taking MMF met the criteria to be considered responders. For the patients treated with MTX, the median follow‐up for the second visit was 178 days and for the last visit was 776 days. For those treated with MMF, the median follow‐up was similar – 147 days for the second visit and 787 days for the last visit. Six patients who received MMF had previously been treated with MTX and one patient who received MTX had previously used MMF. Cutaneous Dermatomyositis Disease Area and Severity Index activity (CDASI‐A) scores for patients receiving methotrexate (MTX) or mycophenolate mofetil (MMF). Inset shows first 180 days of therapy. Blue lines represent responders at first follow‐up; red lines represent nonresponders. [Colour figure can be viewed at wileyonlinelibrary.com] While there was virtually no difference between the daily change in the MTX and MMF groups, the small sample size and nonrandomized design preclude definitive conclusions. However, our findings can provide a preliminary reference for future study design. Small observational studies are also subject to confounders and other biases. To overcome these shortcomings, large randomized clinical trials are needed. Either MMF or MTX may be added to treatment plans for patients with DM who have not responded to antimalarials. Our data suggest that responders continued to improve over many months while most nonresponders showed little improvement at first follow‐up during the observation period. Madison Grinnell: Conceptualization (equal); data curation (lead); formal analysis (equal); methodology (equal); writing – original draft (lead); writing – review and editing (lead). Emily R Keyes: Writing – review and editing (equal). DeAnna Diaz: Writing – review and editing (equal). Thomas Vazquez: Writing – review and editing (equal). Rui Feng: Formal analysis (lead); writing – review and editing (equal). Victoria Werth: Conceptualization (lead); formal analysis (equal); methodology (equal); supervision (equal); writing – review and editing (lead). The data that support the findings of this study are available from the corresponding author upon reasonable request.
Source: British Journal of Dermatology
DOI: 10.1111/bjd.21235
Institutions: Philadelphia VA Medical Center, University of Pennsylvania
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W4221078044