Introduction
Case descriptions
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Case 1: A 55-year-old male was hospitalized with complaints of fevers, skin eruptions, gait disturbance, dysphasia, and dyspnea which had developed in the last 10 days. Gottron’s papules were seen on his fingers, weakness of proximal muscles was found, chest computed tomography (CT) showed bilateral lung opacities, and anti-MDA5 antibody was positive. Under the diagnosis of anti-MDA5-DM-ILD, combination therapy with high-dose GCs, CY, tacrolimus was initiated. Although he got improved transiently, fever relapsed and lung infiltrates had become enlarged on CT (Fig. 1A). Addition of pulse glucocorticoid and PE had limited efficacy. After initiation of baricitinib 4 mg/day, slight improvement of ILD was achieved (Fig. 1B). Although gastric ulcers with a CMV infection (diagnosed by immunohistochemical CMV detection on biopsy specimens) and venous thrombophlebitis developed, they were controlled by antiviral therapy with ganciclovir and anticoagulation, respectively. Five months elapsed before ILD was stabilized, at which time he was discharged on combination treatment with baricitinib. His clinical course was summarized in Fig. 2A.
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Case 2: A 57-year-old male diagnosed with anti-MDA5-DM-ILD was transferred to our hospital for alternative treatment because combination therapy with high-dose GC, CY, and tacrolimus was ineffective. Although he had no fever or dyspnea, he suffered from persistent cough and digital ulcers. Hyperferritinemia (3529 ng/ml at the initiation of therapy and 1855 ng/ml on admission) was also noted. Baricitinib and PE were initiated, which improved ILD (Fig. 1C, D) as well as cough and digital ulcers. Although CMV reactivation (blood CMV antigen detected by phosphoprotein 65 staining was positive: 5.5 per 105 white blood cells (WBCs)) and intestinal pneumatosis developed and required antiviral therapy with valganciclovir and bowel rest, respectively, ILD remained stable on combination treatment with baricitinib (4 mg/d). His clinical course was summarized in Fig. 2B.
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Case 3: A 79-year-old male with seronegative rheumatoid arthritis was hospitalized for fever and dyspnea. Antibiotics administration assuming bacterial pneumonia was ineffective. Since he had facial erythema that was pathologically characterized by perivascular dermatitis with mucin deposition and anti-MDA5 antibody was positive, he was diagnosed with severe CADM-associated ILD with oxygen demand. Treatment with baricitinib, in addition to immunosuppressive therapy with GCs, CY, and tacrolimus, gradually improved the ILD (Fig. 1E, F). However, we were compelled to discontinue baricitinib due to CMV reactivation (blood CMV antigen per 105 WBCs was 228 at maximum). Although it was initially resistant to ganciclovir administration, it gradually subsided after baricitinib withdrawal. Thereafter, ILD followed a smoldering course, and the patient succumbed to successive infections after 6 months of treatment. His clinical course was summarized in Fig. 2C.
Methods
Review of past cases who had been treated with tofacitinib at our institution
Literature review
Statistical analysis
Results
Characteristics and outcome of patients treated with JAK inhibitors at our institution
Jak inhibitor | Baricitinib | Tofacitinib | |||||||
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Patients | Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | Case 6 | Case 7 | Case 8 | Case 9 |
Gender | Male | Male | Male | Female | Female | Female | Female | Female | Male |
Age, years | 55 | 57 | 79 | 62 | 21 | 55 | 73 | 45 | 66 |
Diagnosis | DM | DM | CADM | CADM | DM | DM | DM | DM | CADM |
CK, U/L | 1199 | 634 | 45 | 214 | 220 | 54 | 891 | 311 | 37 |
LD, U/L | 534 | 368 | 247 | 337 | 474 | 257 | 471 | 421 | 570 |
CRP, mg/dL | 0.94 | 2.16 | 4.54 | 0.50 | 1.87 | 0.26 | 3.00 | 0.30 | 0.29 |
Ferritin, ng/mL | 808 | 3529 | 403 | 408 | 429 | 465 | 401 | 1746 | 1694 |
KL-6, U/mL, | 575 | 1320 | 280 | 1085 | 575 | 1719 | 312 | 454 | 458 |
Accompanied autoimmune diseases | None | None | RA | CLE | None | None | None | None | None |
Indication | Treatment resistance | Treatment resistance | Severe disease | Treatment resistance | Treatment resistance | Treatment resistance | Treatment resistance | Switch from previous treatmenta | Disease activity other than ILDb |
Concomitant treatment | GC, CNI, CY, PE | GC, CNI, CY, PE | GC, CNI, CY | GC, CNI, CY, PE | GC, CNI, CY, PE | GC, CNI, CY, PE | GC, CNI, CY, PE | GC, CNI, CY | GC, CNI, CY, PE |
Treatment response | Yes | Yes | Yes | Yes | Yes | No (unchanged) | No (become worse) | NAc | Yes |
Complications | CMV gastritis, venous thrombosis | CMV reactivation, intestinal pneumatosis | CMV reactivation | Pulmonary embolism, venous thrombosis | Bacteremia, BK viral nephropathy | Cytopenia | CMV reactivation, cytopenia, angina, pneumothorax, pneumomediastinum | CMV reactivation | CMV reactivation, liver injury |
Discontinuation due to complications | No | No | Yes | No | Yes | Yes | No | Yes | Yes |
Outcome | Survived | Survived | Deceased | Survived | Survived | Survived | Deceased | Survived | Survived |
Literature review
JAK inhibitors (number of patients) | Tofacitinib (78), Peficitinib (1) |
Gender, male (%) | 32 (40.5) |
Age, years, mean (SD) | 52.9 (11.5) |
Diagnosis (number of patients) | DM (22), CADM (49), NA (8) |
CK, U/L, mean (SD), available number of patients | 212 (507), 40 |
LD, U/L, mean (SD), available number of patients | 366 (178), 61 |
CRP, mg/dL, mean (SD), available number of patients | 1.72 (2.24), 40 |
Ferritin, ng/mL, mean (SD), available number of patients | 1304 (1438), 48 |
KL-6, U/mL, median (IQR), available number of patients | 867 (501), 37 |
Accompanied autoimmune diseases (number of patients) | Psoriatic arthritis (1) Rheumatoid arthritis (1) |
Positioning (number of patients) | Initial (29), Additional (22), Re-induction (2), NA (26) |
Concomitant treatment (number of patients) | GC (78), CNI (32), CY (27), PE (20), RTX (11), IVIG (7), Pirfenidone (4), MMF (2), Unspecified (11) |
Complications | Viral infections (38) CMV (23), herpes zoster (7), others (8) Bacterial infections (12) Respiratory (6), sepsis (4), others (2) Fungal infections (14) Other events Cytopenia (15), Pneumomediastinum (3), Thrombotic microangiopathy (2), Renal dysfunction (1), Venous thrombosis (1), Alveolar proteinosis (1), Liver dysfunction (1), Hepatic failure (1), Shock of unknown cause (1), Intramuscular bleeding (1), Hip fracture (1) |
Number of discontinuation cases due to complications | 11 |
Number of survivors (%) | 60 (75.9) |
Survived n = 60 | Deceased n = 19 | P value | |
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JAK inhibitors (number of patients) | Tofacitinib (59) Peficitinib (1) | Tofacitinib (19) | – |
Gender, male (%), number of identified patients | 20 (39.2), 51 | 8 (61.5), 13 | 0.212 |
Age, years, mean (SD), available number of patients | 50.6 (11.5), 45 | 57.9 (10.8), 8 | Not applicable |
Diagnosis (number of identified patients) | CADM (29) DM (10) | CADM (3) DM (3) | 0.334 |
CK, U/L, median (IQR), available number of patients | 167 (130–404.5), 11 | 155 (123–341.5), 3 | 0.769 |
LD, U/L, mean (SD), available number of patients | 362 (229), 31 | 472 (105), 4 | Not applicable |
CRP, mg/dL, median (IQR), available number of patients | 0.625 (0.295–1.31), 11 | 1.07 (0.63–3.56), 3 | 0.633 |
Ferritin, ng/mL, mean (SD), available number of patients | 1143 (1244), 41 | 2240 (2242), 7 | Not applicable |
KL-6, U/mL, median (IQR), available number of patients | 788.5 (425.75–1104.5), 32 | 802 (661–913), 5 | 0.813 |
Positioning (number of identified patients) | Initial (26) Additional (17) Re-induction (2) | Initial (3) Additional (5) Re-induction (0) | 0.474 |
Number of concomitant treatments per patient, median (IQR), available number of patients | 3(2–4), 33 | 3(2–4), 12 | 0.916 |