Would you treat with cyclophosphamide, IVIG, methotrexate, physical therapy, or prednisone?
An 82-year-old man presents for a follow-up visit for inclusion body myositis. Despite a 4-month prednisone taper, there has been no clinical improvement. Physical examination reveals normal vital signs and unchanged weakness in the shoulders, forearms, hand grip, hip girdle, and knee extensors from previous examinations. His serum creatine kinase level is 370 U/L, minimally decreased from 4 months ago.
Which of the following is the most appropriate treatment?
- Cyclophosphamide: An alkylating agent used as salvage therapy for severe inflammatory myositis refractory to other therapies.
- Intravenous immune globulin (IVIG): Used in patients with polymyositis or dermatomyositis who have an inadequate response to initial combination therapy with glucocorticoids and traditional immunosuppressive agents.
- Methotrexate: Often added to glucocorticoids for combination therapy in most forms of idiopathic inflammatory myopathies to reduce the total amount and duration of glucocorticoid use.
- Physical therapy: Can help patients maintain muscle function for activities of daily living.
- Prednisone: A corticosteroid that was previously administered to the patient without meaningful clinical response.
According to a study published in Neurology, inclusion body myositis affects between 1 and 71 people per million, making it the most common acquired myopathy in patients aged over 50.
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