The incidence of anti-HMGCR immune-mediated necrotizing myopathy: an Australian and UK retrospective multi-site cohort study
Thomas Khoo, Elina Tan, Vidya Limaye, Harsha Gunawardena, Ross Sadler, Janine A. Lamb, Xia Lyu, Anna Brusch, Merrilee Needham, Keziah Austin, Aaron Bahadori, Maya H Buch, Maciej Tomaszewski, James B Lilleker, Hector Chinoy
Abstract
OBJECTIVES: Immune-mediated necrotizing myopathy (IMNM) with autoantibodies targeting 3-hydroxy-3-methylglutaryl-CoA reductase (anti-HMGCR) is considered a rare complication of statin therapy. We calculate the incidence of anti-HMGCR IMNM and describe clinical characteristics in four independent cohorts: Manchester (UK), Bristol (UK), Western Australia (WA, Australia) and South Australia (SA, Australia). METHODS: Adults (≥18 years) with anti-HMGCR IMNM (ENMC criteria; 2018-2023) were identified from myositis clinic and laboratory records. Nationwide UK anti-HMGCR testing was performed at Oxford University Hospital Laboratories and state-based WA/SA testing at PathWest Laboratories. RESULTS: One hundred and nine anti-HMGCR IMNM cases were identified (51% female, median 66 years [IQR 58-72.2]) with median follow-up 2.3 years [IQR 1.5-4.2]. Mean annual incidence was 2.9 cases/million person-years. In statin users, incidence was 20.4 (UK) and 24.1 (WA/SA) cases/million statin-users/year. One hundred and one patients were statin-exposed, mostly atorvastatin (77/101, 76.2%). Median statin duration before diagnosis was 3 years (range: 1 month-23 years). Eight (7.5%) were statin-naïve and, compared with statin-exposed patients, younger (median 46.1 vs 67 years, P = 0.02), frequently of non-white ethnicity (5/8 vs 20/77, P = 0.04) and more commonly had dysphagia (4/8 vs 14/94, P = 0.03). The median peak creatine kinase (CK) was 7020 IU/l (range: 964-39076), and 48/105 (45.7%) received intravenous immunoglobulin. At follow-up, less than half had normal CK (50/105 [47.6%]) or muscle power (48/104 [46.2%]). CONCLUSION: For the first time, we have calculated an incidence of anti-HMGCR IMNM using a large, multinational cohort. We highlight the refractory nature of anti-HMGCR IMNM. We also describe the unique phenotype of statin-naïve anti-HMGCR IMNM, and the rare occurrence of self-limiting myopathy.