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- So the treatment is mostly focused
on suppressing the immune system so that the muscles
are no longer looking foreign to ones own immune system.
So the goal is to suppress the immune system enough
but not too much so that there are not adverse events
that one can see with immune suppression.
The most notable medicine that we use in the beginning
is usually Prednisone which is a longstanding,
it's a long known steroid has been used
for many autoimmune diseases for now decades.
Ideally though steroids in the long run are not ideal.
Lead to long term consequences and so the next thing that
we do is use something called a steroid sparing agent
or a steroid sparing medicine.
The most common of those are known as Methotrexate
and Azathioprine, again these medicines have been used
for decades, we've borrowed them from other
autoimmune diseases and they generally work well
in patients who are mildly effected.
In more severe cases we go on to further immune-suppressants
that are a little bit more intense and therapy.
They can include things such as Mycophenolate, Rituximab,
IVIG which is an intravenous gamma-globulin
which is a intravenous therapy given monthly.
All the therapy that we used is considered off-label.
Which means that there really are very few products
that are indicated for Polymyositis.
ACTH gel which is a longstanding therapy
is FDA approved and has been grandfathered in
over many years to be used for the disease,
and Prednisone is FDA approved.
Beyond that anything that we use is used
what's called off-label currently.
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I cannot stress how important regular physical exercise
and even physical exercise prescribed
by a physical therapist can be.
Physical therapy programs that strengthen the muscle
and increase the endurance are incredibly important.
We generally tell patients not to lift heavy weights,
but light weights with multiple repetitions
can probably help rebuild the muscle.
While we really don't know a whole lot
about exercise and its role in Myocitis
as that's only recently appreciated to be
an important part of the therapy, I think it goes
without saying that the muscles are likely abnormal
under the microscope so that they may be more susceptible
to the effects of exercise that can have
some negative consequences.
So I always recommend that patients titrate
their exercise up carefully.
There was an old paradigm that says when the muscle
is inflamed and affected you should rest it,
and in fact I think that we've come full circle
to realize that that's certainly not true.
So in today's day, as soon as the patient is able,
we get them up and moving in a regular exercise program.
Empirically it's been my own observation
over several years that the patients that exercise more,
and exercise regularly seem to be able to go into remission
and stay there and they tend to do better as a whole.
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Polymyositis can as I've mentioned be really
part of a syndrome, so Polymyositis is rarely just
seen on its own, for example if it's seen in concert
with other autoimmune diseases you very well may need
to see another specialist.
If a person is seeing a neurologist for example,
and their joints are involved a rheumatologist
would be important, if the patient has lung involvement
a pulmonologist that specializes in that
particular type of inflammatory lung disease
which is called interstitial lung disease
would be very important.
We also have our patients see physical therapists
and occupational therapists to work the lower
and upper body respectively, I sort of teased that it says
take a village to take care
of people with Polymyositis sometimes because,
while the primary target is the muscle
it can go well beyond the muscle
and involve many other organs.
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I guess the last thing that I would want people to know
is that I think as we are understanding more
about the biology of these diseases,
like Polymyositis we'll get better at targeting therapy.
I think about it in some ways like the oncology
or cancer paradigm whereas before chemotherapy
essentially was a one shot, we hoped we got the bad guys
but we killed a lot of the good guys
in the body, in the fight.
So I think as we understand immunology in a more
sophisticated fashion we're understanding that
certain pathways are effected more than others.
So I think as time goes on we'll actually have
targeted therapy shutting down just those parts
of the immune system that are effected
and leaving the others alone,
and I think that's incredibly important.
Because the toxicity would likely go down
when you have a very targeted approach.
So I'm hopeful for the future of treatments
for Polymyositis and the related muscle diseases.
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