Mild pain , mild muscle weakness
Or
CK value < 2,5 ULN
Initiate paracetamol/NSAID
If symptom severity increases despite NSAID consider treatment cfr grade 2
Control CK after one week, if increasing: discuss with local myositis specialist
Start corticoids 1mg/kg after discussion with internist/rhumatologist/neuromuscular specialist, continue for at least 1 month even if clinical imporvement after 1 week. If needed add other immunsuppressants so corticoids can be tapered after one month
If no improvement after 48h (pain or CK): 2 mg/kg; if still no improvement 48h later, other immunosuppressants should be discussed with experienced organ specialist
Consider IVIG (no reimbursment in Belgium) or bolus steroids if severe life threatening weakness, less evidence for plasma exchange
Perform examination of joints and skin
Exclude cardiac origin (CKMB/troponin/pro-BNP and ECG) and in case of doubt perform cardiac IRM
Troponin I is more specific of cardiac involvement than troponin T
Exclude other causes of elevated CK: IM injection, physical activity, …
Perform EMG to evaluate myopathic features Assesment of diaphragm motion: X ray and perform respiratory tests both in upright and horizontal position
Perform MRI of affected muscle Consider muscle biopsy before start steroids (should be done by experienced specialist)
Analyze serology before start of steroids (ANF (+further subanalysis), myositis specific antibodies / myositis associated antibodies) (according to local practice) Perform spirometry in order to assess restrictive syndrom (due to paralysis of intercostal muscles)
Rhumato-onco taskforce KBVR/SRBR (Yves Piette, Ellen Delanghe) Gauthier Remiche, ULB Erasme
Olivier Lambotte, AP-HP, Hôpital Bicêtre, Service de Médecine
Interne et Immunologie Clinique, Paris, France,
Dimitri Psimaras, Practicien Hospitalier
Département de Neurologie Mazarin, GHPS, Paris, France
Abbrevation