Treatment Algorithm for Adult Patients with Polymyositis (PM) or Dermatomyositis (DM) - Flowchart

Treatment Algorithm for Adult Patients with Polymyositis (PM) or Dermatomyositis (DM) - Flowchart

Treatment Algorithm for Adult Patients with Polymyositis (PM) or Dermatomyositis (DM) - Flowchart Inflammatory Myopathies Inflammatory Myopathies

«Flowchart»

PM or DM ILD?

PM or DM ILD?

PM or DM ILD?

PM or DM ILD?

Yes

Yes

Yes

No

No

No

Prednisone 0.75–1 mg/kg/day
AZA 2 mg/kg/day or MTX 15–25 mg/wk, folic acid
Supplemental calcium and vitamin D
Bisphosphonates
Exercise

Prednisone 0.75–1 mg/kg/day
AZA 2 mg/kg/day or MTX 15–25 mg/wk, folic acid
Supplemental calcium and vitamin D
Bisphosphonates
Exercise

Prednisone 0.75–1 mg/kg/day
AZA 2 mg/kg/day or MTX 15–25 mg/wk, folic acid
Supplemental calcium and vitamin D
Bisphosphonates
Exercise

Prednisone 0.75–1 mg/kg/day
AZA 2 mg/kg/day or MTX 15–25 mg/wk, folic acid
Supplemental calcium and vitamin D
Bisphosphonates
Exercise

Prednisone 0.75–1 mg/kg/day
CYC 1 g/m² monthly pulses or 1–2 mg/day orally or cyclosporine A 3–5 mg/kg/day or tacrolimus 0.075 mg/kg/day in 2 divided doses
Supplemental calcium and vitamin D
Bisphosphonates
Exercise

Prednisone 0.75–1 mg/kg/day
CYC 1 g/m² monthly pulses or 1–2 mg/day orally or cyclosporine A 3–5 mg/kg/day or tacrolimus 0.075 mg/kg/day in 2 divided doses
Supplemental calcium and vitamin D
Bisphosphonates
Exercise

Prednisone 0.75–1 mg/kg/day
CYC 1 g/m² monthly pulses or 1–2 mg/day orally or cyclosporine A 3–5 mg/kg/day or tacrolimus 0.075 mg/kg/day in 2 divided doses
Supplemental calcium and vitamin D
Bisphosphonates
Exercise

Prednisone 0.75–1 mg/kg/day
CYC 1 g/m² monthly pulses or 1–2 mg/day orally or cyclosporine A 3–5 mg/kg/day or tacrolimus 0.075 mg/kg/day in 2 divided doses ²
Supplemental calcium and vitamin D
Bisphosphonates
Exercise

Taper prednisone
Continue with CYC or switch to tacrolimus, or cyclosporine A or MMF 2–3 g/day or rituximab

Taper prednisone
Continue with CYC or switch to tacrolimus, or cyclosporine A or MMF 2–3 g/day or rituximab

Taper prednisone
Continue with CYC or switch to tacrolimus, or cyclosporine A or MMF 2–3 g/day or rituximab

Taper prednisone
Continue with CYC or switch to tacrolimus, or cyclosporine A or MMF 2–3 g/day or rituximab

Taper prednisone by 10% every 2 wk
Stop CYC, switch to AZA or MTX 15–25 mg/wk, folic acid

Taper prednisone by 10% every 2 wk
Stop CYC, switch to AZA or MTX 15–25 mg/wk, folic acid

Taper prednisone by 10% every 2 wk
Stop CYC, switch to AZA or MTX 15–25 mg/wk, folic acid

Taper prednisone by 10% every 2 wk
Stop CYC, switch to AZA or MTX 15–25 mg/wk, folic acid

At 12 mo
Improved?
Yes: Taper prednisone

At 12 mo
Improved?
Yes: Taper prednisone

At 12 mo
Improved?
Yes: Taper prednisone

At 12 mo

At 18 mo
Remission?
Yes: Try to stop prednisone or taper to lowest maintenance dose.
Taper AZA or MTX to lowest maintenance dose.

At 18 mo
Remission?
Yes: Try to stop prednisone or taper to lowest maintenance dose.
Taper AZA or MTX to lowest maintenance dose.

At 18 mo
Remission?
Yes: Try to stop prednisone or taper to lowest maintenance dose.
Taper AZA or MTX to lowest maintenance dose.

At 18 mo

End

End

End

At 12 mo
Improved? Switch CYC to AZA or MMF 2–3 g/day or MTX 15–25 mg/wk.
No improvement: Consider rituximab.

At 12 mo
Improved? Switch CYC to AZA or MMF 2–3 g/day or MTX 15–25 mg/wk.
No improvement: Consider rituximab.

At 12 mo
Improved? Switch CYC to AZA or MMF 2–3 g/day or MTX 15–25 mg/wk.
No improvement: Consider rituximab.

At 12 mo

Taper prednisone, slowly by 10% every 2 wk

Taper prednisone, slowly by 10% every 2 wk

Taper prednisone, slowly by 10% every 2 wk

Consider increasing MTX dose

Consider increasing MTX dose

Consider increasing MTX dose

Taper prednisone, switch AZA to MTX, or vice versa and re-evaluate diagnosis

Taper prednisone, switch AZA to MTX, or vice versa and re-evaluate diagnosis

Taper prednisone, switch AZA to MTX, or vice versa and re-evaluate diagnosis

Taper prednisone, slowly

Taper prednisone, slowly

Taper prednisone, slowly

Consider rituximab or cyclosporine A or combination AZA + MTX

Consider rituximab or cyclosporine A or combination AZA + MTX

Consider rituximab or cyclosporine A or combination AZA + MTX

Taper prednisone slowly to lowest maintenance dose.
Taper AZA to MTX to lowest maintenance dose.

Taper prednisone slowly to lowest maintenance dose.
Taper AZA to MTX to lowest maintenance dose.

Taper prednisone slowly to lowest maintenance dose.
Taper AZA to MTX to lowest maintenance dose.

At 18 mo
Improved or remission?

At 18 mo
Improved or remission?

At 18 mo
Improved or remission?

At 18 mo

At 6 wk
Improved strength?

At 6 wk
Improved strength?

At 6 wk
Improved strength?

At 6 wk

Yes

Yes

Yes

No

No

No

At 3 mo improved strength?

At 3 mo improved strength?

At 3 mo improved strength?

At 3 mo improved strength?

Yes

Yes

Yes

No

No

No

At 6 mo
Improved?

At 6 mo
Improved?

At 6 mo
Improved?

At 6 mo

Yes

Yes

Yes

No

No

No

At 3–6 mo
PFTs improved?
Improved strength?

At 3–6 mo
PFTs improved?
Improved strength?

At 3–6 mo
PFTs improved?
Improved strength?

At 3–6 mo

Yes

Yes

Yes

No

No

No