Characteristic Treatment Of Polymyositis

Characteristic treatment of polymyositis 

Organization
The Polymyositis Department of Hebei Yiling Hospital has a number of immunological experts available for service, who are dedicated to the research and treatment of polymyositis and dermatomyositis for years with abundant clinical experience and first-class scientific research capability. It has been proven by experiments that the series of medicines developed by them have such functions as enhancing physical strength, immunity and disease resistance as well as promoting parahormone secretion effect so as to adjust several links of the immunologic system. The clinical application of these medicines has shown favorable clinical efficacy. 

Delightful Progress Made in Scientific Research of Jiyanling Capsule

Polymyositis is an autoimmune disease often seen clinically. It is suggested by the modern medical theory to adopt hormone and immunosuppressant for this disease, which however will bring miserable suffering to the patients due to their toxic and side effects. Traditional Chinese medicine, though achieved favorable therapeutic effect against this disease, has never been recognized systematically so far since only few successful cases were reported, which as a result, restricted the research and development of new TCM drugs for clinical applications．

The Polymyositis Project Team of our Immunity Department believes，on the basis of in-depth understanding of TCM theories and long-term clinical observation, that polymyositis should be classified as numbness and atrophic debilitys according to TCM theories, and its principal pathogenesis are loss of nutrient in the extraordinary eight meridians, deficiency of the spleen and kidney, sluggishness and deficiency of vital qi in the collaterals, lack of warmth by yang, failure of essential substances to nourish marrow, deficiency of both yin and yang and affection by exopathogenic wind-cold dampness or rheumatic fever that block collateral channels and lead to impede circulation of qi and blood. Based on this belief, a TCM theoretical solution is suggested concerning this disease to enhance the body resistance, treat atrophy, nourish skin, promote tissue regeneration, invigorate the spleen, tonify the kidney, remove stagnation syndrome of qi and the blood, dissolve the stagnant and activate the channels. Accordingly, TCM preparation--Jiyanling capsule is developed for warming up and regulating yang, warming and invigorating original qi, nourishing essential substances,  expelling wind, clearing away heat and removing dampness. 

Jiyanling capsule has been used clinically for many years and treated more than 2,000 patients with satisfactory efficacy. Recently, to strengthen scientific research, we reproduced successfully experimental autoimmune polymyositis animal model(EAM) with multi-point immunized Lewis rats by the skeletal muscle myosin of guineapig for the first time in China, upon which the efficacy of Jiyanling capsule was validated and compared with that treated with prednisone. As a conclusion, the following efficacies are achieved with Jiyanling capsule. 

Rectifying the clinical symptoms of rats,
Improving muscle strength,
Shortening the time limit of electromyogram, lowering wave amplitude and relieving impairment due to myogen,
Lowering the levels of creatase and anti-myosin antibody in sero,
Rectifying the manifestations of muscular pathology,
Inhibiting the proliferation of lymphocytes in inguinal lymphnodes induced by ConA and Ｍyosin of EAM rats,
The high and intermediate dosage groups are superior to prednisone group in inhibiting the proliferation of rat Ｔ lymphocytes induced by Myosin, and
The high dosage group is superior to the prednisone group in rectifying electromyogram. 
The Transplantation of Muscle Stem Cells Indicates Favorable Efficacy against Polymyositis and Dermatomyositis in Our Hospital

Polymyositis is a chronic inflammatory myopathy that affacts mainly the skeletal muscles of limb proximal ends, cervical muscle and pharyngeal muscle, of which the primary clinical manifestations are myasthenia, muscle tendeness and myatrophy while the principal pathogenic manifestations are denaturizatin, regeneration, necrosis and phagocytosis of muscle fiber as well as infiltration of separate nuclei. The pathogenesis of this disease is still not totally clear. Hormone and immunosuppressant are mainly adopted in the treatment, but their long-term and large-dosage use will bring about serious side effects. Besides, about 1/3 of patients are insensitive to hormone clinically.  Along with the rapid progress of molecular biology and cellular immunology, the transplantation of muscle stem cells against polymyositis has attracted attention from therapeutists. 

What is stem cell then on earth? The great majority of body cells lose the ability of segmentation because of through differentiation, but certain numbers of primitive cells that do not differentiate yet and have self renewal capability will remain in the course of organismic development, which are known as stem cells or source cells. The latest research indicates stem cells exist generally in human body, including the nerve stem cells that were thought unregeneratable. That means the organ or tissue will be possible to resume the normal physiological function if its stem cells are cultivatable. 

To improve efficacy further and free patients from suffering, in addition to Three-stage Immunity Balancing Therapy and Jiyanling capsule for treatment of this disease, a research team of Polymyositis Department led by Vice President Zhang Qingchang and Chief Physician Zhong Qicheng, developed a therapy by combining the transplantation of muscle stem cells with TCM treatment against polymyositis upon the technical advantage that the stem-cell incubator laboratory of Yiling Hospital has. The transplantation of muscle stem cells is to give multi-point injection of high-quality muscle stem cells into the patient body in vivo, four times as a treatment course, which is expected to activate and regain the survival muscle cells inside, replace the denaturized and necrotic muscle cells, correct immune disorder, retard the progress of disease and accelerate the cure process. 

This new technique can relieve patients from clinical symptoms, improve the muscle strength of affected limbs and decrease the incidence rate of visceral lesion to a large extent, so as to improve the patients' quality of life significantly. As a injection transplantation method, it is simple, safe, reliable, no surgical operation needed, less chance to be infected and high survival rate of stem cells. 

Under the guideline of scientificness, preciseness, safety and efficiency,  we would like to serve the myositis patients wholeheartedly for their cure! 

Characteristic treatment of polymyositis 

As autoimmune disease, polymyositis and dermatomyositis are characterized by the cycle of occurrence, remission, recurrence and remission again. The cycle keeps repeating and aggravating progressively. Concerning such type of functional disorder of autoimmunity and different stages as below, the scientific personnel like Chief Physician Zhang Qingchang from Hebei Yiling Hospital put forward the Three-stage Immunity Balancing Therapy on the basis of TCM and developed Jiyanling series of medicines, which can adjust the unbalanced immunological state of polymyositis patients and get cured eventually.  

In the early stage, the patients of polymyositis or dermatomyositis have such symptoms as lightly sore muscle, uncomfortable joints, physical fatigue, weakness or irregular skin rash or irregular fever. The key to the treatment is to adjust and support body 's control system, establish a dynamic balance of organism and rectify the immune disorder prematurely. 

In the acute stage while patient is suffering from sore muscle, weakness and limited motivity of the extremities, it is suggested to take the first step of the therapy, that is, to control the disease quickly and prevent it from further development. In this step, eliminating pathogenic factors should dominate strengthening the body resistance. 

In the intermediate restoration stage, the second step of the therapy should be taken to eliminate evil factors and support healthy energy. Specially, it is suggested to improve the immunological function, enhance muscle strength, promote muscle growth, rectify dyspnea, dysphagia and myatrophy as well as regain skin elasticity and color by warming yang, supplementing qi, nourishing yin and clearing away the heat-evil. For those patients who are taking hormone, it is suggested to stop it gradually along with the immunological system getting balanced; meanwhile, measures should be taken to inhibit the sthenic autoimmune function, eliminate such symptoms as sore muscle, weakness and limited motivity of the extremities and lower the high level of sero enzyme through dissolving the stagnant and detoxification. 

In the clinical remission stage, it is suggested to take the third step of the therapy to strengthen the body resistance mainly with eliminating pathogenic factors as supplement. It is purposed to consolidate the effect and terminate relapse by activating patients’ own resistance against disease through balancing immunological function. The treatment in this stage should adopt the guideline of mild medication to prevent evil dryness, overnourishing, hurting vital-qi and residual evil, so as to balance yin and yang, eliminate pathogen and recoverthe vital-qi ultimately.  

Green Therapy--Chinese Medicated-bath Therapy
Medicated bath, classified as one of TCM external therapies, is to have patient soak some of his or her body parts under hot water that is added with some special herbs. The purposes of treating disease and health preservation will be achieved by stimulating skin, acupuncture points, channels and collaterals with water temperature and skin absorption of drugs. Different from common bath or hot spring bath, it adopts different herbs for different diseases according to the TCM guideline of determining treatment on the basis of differentiating symptoms and signs. Since the medicines will act directly on skin and enter blood circulation system through skin absorption rather than going through stomach and intestine that might affect the medicine effect, it has such advantages as quick efficacy, comfort, no toxic or side effect and nor loading burden on liver. Therefore, it is known as a "green therapy" by the medical world and accepted by patients increasingly. 

Chinese medicated-bath therapy can be traced back to the ancient time of China. In some very old Chinese medical books like "Prescription against 52 Types of Diseases", "Li Ji (Book of Rites)" and "Book of Medicine of the Yellow Emperor", there were contents about such therapy against such as baby epilepsy head, sorehead and body sore. In one word, the medicated-bath therapy has a long history, which originated from Qin Dynasty, developed in Han and Tang Dynasty, enriched in Song and Ming Dynasty, and matured in Qing Dynasty. 

Medicated-bath therapy is basically divided into partial medicated bath and whole-body medicated bath, the former focuses on soaking feet and lower legs. According to TCM theory, the foot region is an important terminal part to activate qi and blood circulation, interconnect the internal organs and link channels and collaterals internally and externally, up and down, where both three yang channels and three yin channels of the foot are interfaced. Meanwhile, foot, composed of 52 pieces of bone and over 60 bundles of muscles, is known as the 2nd heart of human body for it has reflecting regions of internal organs and other parts of body. Lower leg has relatively thin horny layer and plenty of blood vessels, nerves and muscles which are favorable for skin absorption of drugs. As for whole-body medicated bath, it is intended to soak and steam all body parts except head and cervical part, which is suitable for systemic diseases with extensive affects due to larger active area and higher utilization rate of drug. 

Skin, as the largest organ of human body, not only resist exopathogens, but also plays the roles of secretion, absorption, permeation, excretion and sensation. Medicated bathing therapy is devised so as to achieve the purpose of treating diseases with the physiological functions of skon, of which the mechanism of action includes local effect and entire effect. The local effect is achieved by having drugs to act directly on the body surface, muscles and joints so as to rectify their metabolism, resume their functions and exert directly the therapeutic effect with regards to the location of the disease and pathogenesis. The entire effect is acquired by skin absorption of drug into the blood circulation so as to regulate the yin and yang, qi and blood as well as internal organs' function of the whole body. A Chinese therapeutist already summarized the above therapeutical effects of medicated bathing therapy as early as in Qing Dynasty. 

For scleroderma, whether scleroderma circumscriptum or systemic scleroderma, the remarkable cardinal symptom is skin manifestations. A definite diagnosis can be made based on the typical skin symptoms for most patients. By acting directly on skin and joints, medicated bathing therapy can not only rectify such skin symptoms as swelling, sclerosis, atrophy, pigmentation, depigmentation, arthrodynia, contracture, deformity, Reynauds syndrome, etc., but also regularize internal organs' functions. Besides, it has evident efficacy for lesions to internal organs caused by systemic scleroderma. 

Medicated bathing therapy has such functions through drug action, water temperature and magnetic therapeutical effect as regulating qi and blood, balancing yin and yang, dredging the channels, penetrating junctures between the muscle and the skin, expelling evil factors, normalizing function of the stomach and spleen, expelling pathogenic cold from channels, expelling wind and removing dampness, clearing away heat and toxic material, promoting the subsidence of swelling, dispersing accumulation of pathogen, activating the channels for pain relief, nourishing skin, promoting tissue regeneration and aesthetic health care. It is efficacious for treatment not only of stubborn rheumatic diseases such as scleroderma, polymyositis and rheumatic arthritis, but also of asomnia, constipation and fracture, which brings about hope for the patients suffering from such stubborn diseases and achieves breakthrough in efficacy and popularity in patients. 

Breakthrough Progress Made in TCM Treatment of Polymyositis
TCM Jiyanling Capsule Developped by Hebei Yiling Hospital Has Passed Expert Appraisal
(News by our stuff reporter), Recently, the project known as "Experimental and Clinical Study of TCM Jiyanling Capsule Treatment of Polymyositis" undertaken by the research team led by Prof. Wu Yiling, concurrently supervisor of doctoral students of Yiling Hospital Affiliated to Hebei Medical University, has passed the technical appraisal organized by Hebei Provincial Science and Technology Department and concluded as advanced internationally, which symbolizes a significant breakthrough in TCM treatment of polymyositis in China. 

Polymyositis is a specific autoimmune and inflammatory disease that involves mainly the striped muscle with cause unclear yet. It is characterized by such symptoms as symmetrical myasthenia of the limb proximal ends along with myalgia and/or muscle tendeness as well as muscular dystrophy in the late stage. The modern therapeutic methods include mainly application of glucocorticoid, immunosuppressant, plasma exchange and shock of gammaglobulin in treatment of polymyositis, which have predominant advantage for serious cases and those in acute stage, but their applications are restricted by the toxic or side effects. Considering the fact that there is no Chinese patent medicine in market for this disease so far, a project team led by Prof. Wu Yiling started the treatment research of this disease with TCM as early as in 1990s. On the basis of traditional Chinese medical theories and medication against arthralgia syndrome and atrophic debilitys, Prof. Wu Yiling and et al believe through in-depth study that, polymyositis is caused by loss of nutrient in the Extraordinary Eight Meridians, sluggishness and deficiency of vital qi in the collaterals and collateral obstruction by evil factors. Therefore, it should be classified as numbness and atrophy type as per TCM theory and treated through eight extra channels as collateral disease. Accordingly, a therapeutic method is established to enhance the body resistance, treat atrophy, nourish skin, promote tissue regeneration, invigorate the spleen and tonify the kidney on the basis of expelling evil factors, removing numbness, dissolving stagnant and activating the channels. Therefore, a TCM Jiyanling prescription was worked out and produced into TCM Jiyanling capsule against this disease strictly pursuant to technology and quality standard. 

For the purpose of validating the efficacy and mechanism of action further, the project team cooperated with Beijing University of Chinese Medicine on the experimental research of Jiyanling capsule in treatment of polymyositis, and the result turned out that Jiyanling capsule is efficacious in rectifying the clinical symptoms of EAM rats, improving their muscle strength, shortening the time limit of electromyogram, lowering wave amplitude, relieving impairment due to myogen, lowering the levels of creatase and anti-myosin antibody in sero, rectifying the manifestations of muscular pathology, inhibiting the lymphocytic proliferation of inguinal lymphnodes of EAM rats induced by ConA and Myosin in addition to inhibition of non-specific immune reaction. Besides, it indicated that both high-dose group and medium-dose group are superior to prednisone group in inhibiting the proliferation of rat T lymphocyte induced by Myosin as well as rectifying electromyogram (high dose group). The pharmacodynamic study also implies that Jiyanling capsule adopts an immunoregulation mechanism in treatment of EAM, which is different from that of western medicines like steroids and immunosuppressants. And no evident toxic or side effect is found with Jiyanling capsule in toxicological examination. 

Jiyanling capsule has been clinically used for more than 10 years and has gained favorable effect. In order to evaluate the clinical effect of this drug objectively, a Jiyanling group, a prednisone group and a Jiyanling plus prednisone combined group were observed and compared. According to the result, the Jiyanling Group does not differ significantly from the Prednisone Control Group in clinical effect score, decrease of creatase in sero and elevation of mean time limit as well as wave amplitude of electromyogram at the examined part. Either group above are inferior to the Combined Group in comprehensive treatment effect. Obvious excellence of Jiyanling Group on the TCM symptoms improvement is observed, but no significant difference from the Combined Group. However, no side effect like increased fasting blood sugar, increased lipid level or central obesity is observed with the Jiyanling Group, though they are found with the Prednisone Group. All these research results lead to a conclusion that Jiyanling capsule is a safe and effective TCM preparation against polymyositis. 

PE Therapy against Polymyositis/Dermatomyositis
 
PE(plasma exchange) therapy is a new blood purification practice to have patient's blood running through a tailor-made plasma exchanger to replace the isolated abnormal plasma with normal plasma or substitute liquid so as to remove the unwanted substances such as auto antibody, immune complex, high-fineness substances and protein-bound toxic substances, and eventually to treat some diseases that are insensitive to conventional therapies by lightening the impairment to internal organs. For the patients who are suffering from systemic lupus erythematosus, rheumatoid arthritis, polymyositis and dermatomyositis, there are large amounts of circulating immune complexes in their plasma that will result in visceral lesion. Plasma exchange is a short-term adjuvant therapy in the course of rheumatism treatment. It is reported that the efficacy may last for several months once a plasma exchange operation is given. It is suggested to replace 1 to 1.5 liters of blood for once, 2-3 times per week and last 2 or 3 weeks. In the process of plasma exchange, the effect can be strengthened by adopting hormone and immunosuppressant additionally. 

Plasma exchange therapy is relatively safe, but it does not mean no side reaction and certain risk absolutely. The major side reactions include ①hypopiesia, of which the occurrence rate can be reduced through fluid replacement, ②high blood volume, congestive cardiac failure, ③ cardiac arrhythmia, which is generally transient and along with pyknocardia, bradycardia, premature beat and atrial fibrillation occasionally, ④allergic reaction, ⑤ hypocalcemia, hypomagnesemia and hypokalemia, ⑥infection and fever, ⑦leukopenia, thrombocytopenia, hemorrhagic tendency, ect. 

As autoimmune disease, polymyositis and dermatomyositis are characterized by the cycle of occurrence, remission, recurrence and remission again. The cycle keeps repeating and aggravating progressively. Concerning such type of functional disorder of autoimmunity and different stages as below, the scientific personnel like Chief Physician Zhang Qingchang from Hebei Yiling Hospital put forward the Three-stage Immunity Balancing Therapy on the basis of TCM and developed Jiyanling series of medicines, which can adjust the unbalanced immulogical state of polymyositis patients and get cured eventually.  

In the early stage, the patients of polymyositis or dermatomyositis have such symptoms as lightly sore muscle, uncomfortable joints, physical fatigue, weakness or irregular skin rash or irregular fever. The key to the treatment is to adjust and support body 's control system, establish a dynamic balance of organism and rectify the immune disorder prematurely. 

In the acute stage while patient is suffering from sore muscle, weakness and limited motivity of the extremities. It is suggested to take the first step of the therapy to control the disease quickly and prevent it from further development. In this step, eliminating pathogenic factors should dominate strengthening the body resistance. 

In the intermediate restoration stage, the second step of the therapy should be taken to eliminate evil factors and support healthy energy. Specifically, it is suggested to improve the immune function, enhance muscle strength, promote muscle growth, rectify dyspnea, dysphagia and myatrophy as well as regain skin elasticity and color by warming yang, supplementing qi, nourishing yin and clearing away the heat-evil. For those patients who are taking hormone, it is suggested to stop it gradually along with the immunity system getting balanced; meanwhile, to inhibit the sthenic autoimmune function, eliminate such symptoms as sore muscle, weakness and limited motivity of the extremities and lower the high level of sero enzyme through dissolving the stagnant and detoxification. 

In the clinical remission stage, it is suggested to take the third step of the therapy to strengthen the body resistance mainly with eliminating pathogenic factors as supplement. It is purposed to consolidate the effect and terminate relapse by activating patients' own resistance against disease through balancing immunological function. The treatment in this stage should adopt the guideline of mild medication to prevent evil dryness, overnourishing, hurting vital-qi and residual evil, so as to balance yin and yang, eliminate pathogen and recover the vital-qi ultimately. 

Experts Introduction
Mr. Zhong Qicheng, Chief Physician and Professor
Mr. Zhong is the deputy director of the Treatment Center of Rheumatism and Immune Diseases. He was graduated from the Department of Traditional Chinese Medicine of Jiangxi College of Traditional Chinese Medicine, received further education in rheumatism and immunological diseases and has been engaged in clinical practices of TCM and Western medicine for almost 20 years. He has solid knowledge in the theories of both TCM and Western medicine and rich clinical experience. He has profound scientific attainments in the treatment of lupus erythematosus, Behcet's disease, Sjogren syndrome, scleroderma, polymyositis, rheumatoid diseases, etc. The dredging therapy through local injection into the parotid gland for treatment of Sjogren syndrome is his original creation. The therapy is very unique and is with very remarkable therapeutic effects. Mr. Zhong has mastered the two sets of therapies, both the TCM series and the Western series, for the treatment of the above-mentioned diseases. He is very accomplished in taking the advantages of TCM to reduce and avoid the toxic and adverse reactions of Western medicines and reduce the risks of Western medicines. Following the principle of diagnosing and treating diseases on the basis of an overall analysis of the illness and each patient 's conditions, he developed individualized therapies specific to different patients and different stages of the illness. So many cases of success have been achieved that they won him the hearty trust from the patients. 

Mr. Zhong has been involved in the compiling of two academic books up to 800,000 Chinese characters in total. He published more than 30 technical papers on professional journals of the national or the provincial level, 2 papers on international journals, which won him international prize of excellent papers, and 2 academic books. He has taken part in the research work in numerous research projects of the national or the provincial level and was selected as an Excellent Middle Aged TCM Doctor. Two of his achievements have been promoted in such areas like the Central China. His name has been listed in the "Chinese Scientists and Remarkable Experts Collection" and the "The Dictionary of Famous Chinese Doctors". He is invited as the director of the China Association of Famous Doctors, the International Traditional Medicine Association of Canada, and the Hong Kong International Association of Traditional Medicine. He enjoys certain popularity both inside and outside China. 

Solutions to Difficult Problems in Treatment of Polymyositis

Dermatomyositis is a complex and intractable desmosis that involves not only skin and muscle but also the tissues of internal organs. With unfavorable prognosis, it might result in death in some serious cases. The treatment with corticosteroids and immunosuppressants has certain therapeutic effects, however, it requires long-term administration of these drugs in large dosages to achieve such effects. So it is very likely to cause severe toxic and adverse reactions as well as complications. So the problems of controlling the disease development and reducing the toxic and adverse reactions of Western medicines are two key difficult points in the treatment. 

Key Problem: How to Control the Disease Development
Dermatomyositis might lead to death in emergency attacking cases with rapid progress. The comprehensive treatment combining TCM with western medicine is maily adopted in clinical treatment, of which hormone is predominant in western medicine. For some individual cases, the progress of this disease is hard to control even if high-dose hormone is applied, which brings about certain difficulty to the treatment. Therefore, early application and high dose of hormone is suggested in the treatment of dermatomyositis. For those cases that are insensitive to hormone therapy, it is suggested to combine immunosuppressant and cyclosporin A together. Besides, examination should be taken for any occurrence of malignant tumor. If any, corresponding medical care should be given ASAP. Meanwhile, other therapies should be considered such as plasma exchange therapy, radiation therapy, ect. In terms of TCM, it adopts such methods as removing toxic heat, invigorating the spleen, warming the kidney as well as replenish qi and the blood to harmonize yin and yang as well as qi and blood based on differentiation of symptoms and signs. On the one hand, it can reduce the side effects of hormone; on the other hand, it can regularize body's immunologic function and usually help with the control of disease development sooner. 

How to Reduce the Toxic and Adverse Reactions of Western Medicines

It is generally believed that dermatomyositis is a kind of severe autoimmune disease. The treatment with corticosteroids and immunosuppressants has certain therapeutic effects, however, it requires long-term administration of these drugs in large dosages to achieve such effects. So it is very likely to cause severe toxic and adverse reactions as well as complications, and even deaths. So the problem of reducing the toxic and adverse reactions of Western medicines is one of the key difficult points in the treatment. In order to reduce the toxic and adverse reactions we need to assure the following points. 

1. Clinical and sero enzyme tests shall be performed periodically during the hormone treatment period. At the same time, potassium chloride (1g and 3 times a day) or 10% potassium chloride solution (oral administration, 10ml and 3 times a day) shall be administered in order to prevent the myasthenia caused by hypopotassemia. Hormones containing fluorin, such as dexamethasone and omcilon, shall be avoided as much as possible to prevent hormonal myopathy.  
2. It is suggested to adopt integrated Chinese and Western therapies and make full use of the functions of TCM in strengthening the body resistance, eliminating pathogenic factors, invigorating the blood circulation, activating the channels, and harmonizing yin and yang to improve the therapeutic effects and reduce the dosages, the toxic and adverse reactions, and the complications of hormones and immunosuppressants. Generally speaking, hormones shall be used as the major therapy for patients in the acute stage, along with TCMs for removing toxic heat, cooling the blood and harmonizing yin and yang. After the acute state, the principal drug shall be TCMs for nourishing the kidney and the liver, supplementing qi and nourishing yin, invigorating the spleen, tonifying the kidney, and activating blood circulation to dissipate blood stasis. And immunomodulators shall be administered orally or through injections as the adjuvants to regulate the immune function. The hormones and immunosuppressants shall be reduced and withdrawn gradually. And acupuncture, Chinese traditional manipulation, massage, physical therapy, etc. can be used to promote the therapeutic effects and reduce the occurrence of adverse reactions and complications.   
  
What Are the Causes to Polymyositis and Dermatomyositis? 

These questions are frequently asked by patients: Why there is no manifestation of infection since both polymyositis and dermatomyositis are muscle inflammatory diseases? Why they are insensitive to antibiotics? What the earth are the causes to these diseases? To answer these questions, the pathogenesis has to be identified. However, so far, the definite pathogenesis of these diseases are still unclear, and it might be related to infection, body immunologic abnormality, vessel lesion and/or genetic factors. Through the findings of immunoglobulin, complement deposition and inflammatory cell infiltration in biopsy specimen of muscle and the elevation of immunoglobulin in blood as well as positive test result of auto antibody like antinuclear antibody(ANA), rheumatoid factor and anti-J0-1, it indicate that the pathogenesis is related to immunologic abnormality. It was found that multiple infections by such as bacteria, virus, fungus or protozoon might be related to this disease, among which especially viral infection may lead to disorder of immunological adjustment in vivo and cause pathological changes of skin, muscle and internal organs. For children dermatomyositis, the pathological changes of vessel are more predominant. Though the research result of genetic factors was reported occasionally, it does not mean polymyositis or dermatomyositis is hereditary. It is found in research study that the occurrence of HLA-B27 gene in adult polymyositis and children dermatomyositis cases is relatively high. Besides, malignant tumor, immunization, drug intake, alcoholism, trauma, surgery and some endocrine diseases may also induce nonspecific inflammation of skin and/or muscle, and thus this disease. 

Polymyositis Overview
Polymyositis, as a systemic desmosis, is characterized by pathological changes like inflammation and denaturizatin of muscular tissue; meanwhile, skin may be affected frequently and form dermatomyositis, which as a result will lead to symmetrical amyasthenia and myatrophy to centain extent, mainly of limb girdle. 　　

Myositis can be further classified as primary idiopathic polymyositis, children dermatomyositis or polymyositis, adult primary idiopathic dermatomyositis, inclusion body myositis, dermatomyositis or polymyositis complicated with malignant tumor, polymyositis or dermatomyositis complicated with various desmosis overlap syndrome, which includes mixed connective tissue disease and sclerosing dermatomyositis. Polymyositis and dermatomyositis share some clinical manifestations with progressive systemic sclerosis and SLE or vasculitis in some cases. Basically, dermatomyositis is a diffuse inflammatory disease involving skin and muscle. It is known as polymyositis(PM) for the cases that only muscles are involved. 

Typical skin lesions caused by dermatomyositis are edematous mauve plaques around eyelids and symmetrical keratinized red maculoopapular eruption on the extension sides of finger joints, elbow and knee joints along with fine squama on the surface. Muscular lesions are characterized by amyasthenia, soreness, haphalgesia, swelling and atrophy of muscles symmetrically at the limb proximal ends. It might also involve esophagus, pharyngeal portion, heart, lung and liver along with systemic symptoms such as irregular fever, arthrodynia, hemopthisis, leanness, hypodynamia, ect. 

This disease is often seen with people at the age of between 35 and 60, but also with other ages. The percentage of female patients is higher than male patients, up to 2:1 as reported. Some patients often suffer from malignant tumor as well, and the chance increases along with the age grows. 

Distinctive Characeristics for Diagnosis: 
1. Skin lesions are characterized by mauve edematous plaques around upper eyelids, Goftront syndrome as well as dark red spots and ecchymosis on the nailfolds. 
2. Generally, amyasthenia and myalgia are sensed at the limb proximal ends initially, then the affected parts become hardened. In the late stage, it shows pathologic leanness, myatrophy and fibrosis. 
3. At least one test item is found elevated among creatine, aldolase, lactate dehydrogenase and creatine phosphokinase level of total volume urine. 
4. Electromyogram indicates muscle-derived change and the myoelectric potential of affected muscles drops evidently. 
5. Pathological examination indicates cross-striation vanishing, denaturizatin, necrosis of muscle fibers and inflammatory cell infiltration of mesenchyme. 

TCM Viewpoints of Polymyositis
With years' research, we think polymyositis and dermatomyositis should be classified as the TCM category of rheumatism with the muscle involved and atrophic debilitys. The major pathological mechanisms are affection by the six exogenous factors and internal injury by the seven emotions on the basis of congenital deficiencies and lack of proper care after birth, which lead to imbalance of yin and yang, improper circulation of body fluid, qi and blood as well as production of pathological products like sputum, dampness, damp heat and blood stasis that convert into toxic factors for long stasis of collateral channels. 
Based on the above viewpoints, a principle of treatment was established to warm yang for the origin as well as remove toxic substances, eliminate pathogenic factors and activate the channels for the superficiality. The scientific personnel like Chief Physician Zhang Qingchang from Hebei Yiling Hospital put forward the Three-stage Immunity Balancing Therapy on the basis of TCM and developed Jiyanling series of medicines, which can adjust the unbalanced state of polymyositis patients, resume their normal immunological function and get cured eventually. 
In the acute stage, concerning such symptoms as sore muscle, weakness and limited motivity of the extremities, it is suggested to take the first step of the therapy, that is, to inhibit immunological abnormality by eliminating pathogenic factors on the basis of strengthening the body resistance with Chinese herbs like oldenlandia and fiveleaf gynostemma, so as to prevent the disease from further progress quickly.  
In the intermediate restoration stage, the second step of the therapy should be taken to eliminate evil factors and support healthy energy simultaneously. Specifically, it is suggested to improve the immunological function, inhibit the sthenic autoimmune function, lower the high level of sero enzyme, enhance muscle strength, promote muscle growth, rectify dyspnea and dysphagia by warming yang, supplementing qi, nourishing yang and clearing away the heat-evil with TCM herbs like astragalus root, morinda root and isatis root. For those patients who are taking hormone, it is suggested to stop it gradually along with the immunity system getting balanced, meanwhile, to eliminate such symptoms that happen in the acute stage as sore muscle, weakness and limited motivity of the extremities.  
In the clinical remission stage, it is suggested to take the third step of the therapy, that is, to strengthen the body resistance on the basis of eliminating the pathogenic factors. Specifically, it is intended to balance the immunological functions and activate the body resistance against the disease with TCM herbs like ginseng, siberian solomoseal rhizome, cordyceps and barbed stullcap so as to achieve the purpose of consolidating the treatment effect and preventing from its relapse. The clinical practice and sport experiments have confirmed that the Jiyanling series of preparations developed on the basis of Three-stage Immunity Balancing Therapy have evident efficacies in rectifying patient symptoms and physical signs such as choke cough at intake of water, dysphagia, dysarthria, chewing difficulty, ect. and prevence from recurrence. 

How to Diagnose Polymyositis and Dermatomyositis? 

While a patient see a doctor for such symptoms as myalgia, amyasthenia, ect., the diagnosis should be concluded on the basis of careful physical examination, identifying the natures of amyasthenia or skin rash and necessary accessory examnations. The following criteria are relatively practical for diagnosis of this disease.
① symmetrical amyasthenia of proximal ends, 
② muscle biopsy,
③ elevated activity of sero creatase, 
④ electromyogram indicating muscle-derived lesions, and 
⑤ typical skin rash of dermatomyositis. The case in conformity with the first 4 criteria can be diagnosed as polymyositis. The case in conformity with the first 3 or 4 criteria plus the 5th criterion can be diagnosed as dermatomyositis. It is not difficult to diagnose typical polymyositis and dermatomyositis. However, for suspicious cases, the diagnosis must be made in consideration of other examination results like antibody determination and differentiation from other rhematic diseases and inflammatory myopathy. After polymyositis or dermatomyositis is diagnosed firmly, attention should also be paid for if any tumor and any accompanying infection. These examination will be favorable for the treatment next step. 

Clinical Manifestations of Polymyositis

The attacks of dermatomyositis are mostly chronic, and only few cases become acute or subacute onset. There are precursory symptoms in some cases like irregular fever, Raynaud phenomenon, listlessness, fatigue, arthralgia, ect. Dermal and muscular symptoms are two sets of cardinal symptoms for this disease. Skin lesions often appear several weeks or years earlier than muscle lesions, and only few cases are attacked with myopathy while in some cases, both types of lesions attack simultaneously. 

1. Skin Symptoms and Physical Signs
Edematous mauve plaques appear around the eyelids and orbits to various extent. Along with the progress of the disease coruse, mauve pimples may appear the extension surfaces of limbs, elbows, knees, ankles, metacarpophalangeal joints and digital articulation joints, which will join together and become atrophic along with telangiectasis, hypopigmentation and fine squama, namely, Coftron syndrome. Besides, buildup of nail sublots along with rigid telangiectasis and ecchymosis can be seen with the wrinkle of nail root. In some disease cases, skin rash may appear on the trunk, diffuse or local dark red plaques. In some individual cases, the skin rash appears bright red, fire red or red brown on the basis of poikiloderma-like skin rash, which, known as malignant erythema, implys highly that there comes along malignant tumor. Light sensitiveness can happen with 75% to 80% DM patients, of whom the skin rash can be seen where the body is exposed to the sun. The skin rash will increase or aggravate after sun exposure; therefore, the skin rash is more difficult to control in spring and summer. 
　
2. Muscular Symptoms and Physical Signs　
This disease, where the striped muscle of proximal ends are involved as main manifestation, is characterized by symmetrical amyasthenia of limb proximal end. The patients usually feel weak muscle, and then muscular pain, tendeness and kinesalgia. Along with the descent muscle strength, various dysfunctions of motion may appear. Generally speaking, most patients suffer from difficulties in raising arms, head movement, standing up after crouching and/or awkward gait. In some cases, unusual stances might occur with patients due to sudden attenuation of muscle strength such as nose drop, forward lean of shoulders, etc. In the cases that the pharyngeal muscle, the upper part muscle of esophageal and gnathic muscle are affected, Hoarseness of voice and dysphagia may happen with the patients. If the diaphragmatic muscle and intercostal muscle are involved, short breath and dyspnea would appear. Cardiac failure would be caused in case of involvement of myocardium, and ambiopia might occur if ouclar muscles are involved. It was reported that the syndrome like myasthenia gravis ever occured with PM patients, namely, painless muscular

3. Other Symptoms and Physical Signs
Irregular fever might happen with approximately 40% of PM patients along with occasionally joint pain, deformity of elbow, knee, shoulder and finger joints as well as limited motion of joints. There is no evident swelling with superficial lymph nodes generally, though cedrvical lymph nodes might become swollen in a cluster in few cases. Heart functions may go abnormal and the patients may suffer from tachycardia, bradycardia, heart dilatation, myocardial damage and atrial fibrillation as well as occasionally from pleurisy, interstitial pneumonia, calcareous deposition and excretion or subcutaneous nodule. The patients might suffer from slight or moderate swelling of liver in about 1/3 cases, in some of which it might happen simultaneously with other connective tissue diseases or malignant tumor. Upper respiratory infection is often seen with baby patients, and diffuse or local calcium deposit in skin, muscle or aponeurosis is more common with them then adult patients. 

4. Common Complications
The common complications with dermatomyositis include malignant tumor, interstitial pneumonia, myocarditis, fungal meningitis, septicemia, hemorrhage of digestive tract, perforation of gastrointestinal tract, ect. 


Medication against Polymyositis
Under the treatment principle of Three-stage Immunity Balancing Therapy, in order to treat both the principals and the secondary aspects, treatment of the disease and tonification of the body shall be used in combination to regulate the overall immune system, inhibit the immunological reactions, eliminate the clinical symptoms and keep the disease under control. We developed the series of Jiyanling pure TCM preparations with modern pharmaceutical technologies based on the different clinical manifestations of dermatomyositis and the specific conditions of different patients. It has been proven by experiments that the series of medicines developed by them have such functions as enhancing physical power, immunity and disease resistance as well as promoting parahormone secretion effect so as to adjust several links of immunologic system. In addition, it can relieve such syptoms as stagnated heat, blood stasis and sputum stasis so as to achieve such purposes as smooth circulation of body fluid, qi and blood, metabolism acceleration, reduction of effusion and porliferation of collagen tissues, promoting the resumption of affected tissue. The clinical application of these medicines has shown favorable clinical efficacy with the distinct effect rate of 85% and a total efficacy rate of 98.82%. The rational use of Jiyanling series of medicines must be based on the theories of TCM and strictly follow the differentiation of syndromes and signs according to TCM. The Jiyanling series of medicines shall be used following the doctor's instructions and according to the differentiation of syndromes and signs for different patients. The patients shall never use these preparations according to their own discreet to avoid unfavorable influences to the therapeutic effects. 

Jiyanling series of medicines plus Three-stage Immunity Balancing Therapy are applicable for various polymyositis and dermatomyositis patients. 

Jiyanling Medicinal Granules No.1: Mainly applicable for myositis in the acute stage or the late stage with such symptoms as suppression in the chest, short breath, dyspnea, hoarseness of voice, excessive sputum, difficulty to expectorate due to respiratory muscle affected.  

Jiyanling Medicinal Granules No. 2: Mainly applicable for myositis in the acute stage or late stage with such symptoms as choke cough at intake of water, dysphagia, masticatory atonia, dyslalia, difficulty to stick out of the tongue.  

Jiyanlin Medicinal Granulesg No.3: Applicable for myositis in the early stage with such symptoms as muscular swelling and pain, sourness, swelling, low fever, weakness, skin lesion, skin rash and edematous erythema due to rheumatic fever depressed inside skin and unsmooth circulation of qi and blood.  

Jiyanling Medicinal Granules No.4: Applicable for myositis with such symptoms as distension in the abdomen, loss of apetite, deficiency of food, nausea,  vomiting, loose bowels, bitter taste and yellow urine due to retardation of damp heat. 

Jiyanling Medicinal Granules No. 5:  Applicable for myositis with such symptoms as myatrophy, descent muscle strength, atrophy of limbs, body weakness or even flaccid paralysis symptoms like walking difficulty, disability of walking, etc due to the whole body involved.  
 
Jiyanling Medicinal Granules No.6: Applicable for deficiency of yin and interior heat type of myositis with such symptoms as thirsty mouth,  dry tongue, dry cough without sputum, feverish sensation in the palms and soles as well as dryness of the skin. 

Jiyanling Capsule No.7:Applicable for the type of myositis with such symptoms as body leanness, tiredness,  weakness, short breath,  spontaneous perspiration, persistent low fever, palpebral edema, poor appetite, loose stool and abnormal immunologic functions due to deficiency of the spleen and kidney, stasis of damp heat, weakened body resistance and domination of pathogen.  

Jiyanling Capsule No. 8: Applicable for myositis with such symptoms as vertigo and tinnitus, chilly sensation and the cold limbs, soreness of the waist and knees, apontaneous emission, impotence invirility, frequent micturition, Raynauds phenomenon(cyanosis of both hands at low temperature), pale tongue with thin coating,  slow and sunken pulse, ect. due to deficiency of essential qi, kidney yang deficiency and poor warming function. 

TCM Jiyanling Capsule Passed Expert Appraisal
The TCM Treatment of Polymyositis Achieved Breakthrough Progress
TCM Jiyanling Capsule developped by Hebei Yiling Hospital Is through Expert Appraisal

(News by our stuff reporter). The project known as "Experimental and Clinical Study of TCM Jiyanling Capsule in Treatment of Polymyositis" undertaken by the research team led Prof. Wu Yiling, concurrently the supervisor of doctoral students of Yiling Hospital Affiliated to Hebei Medical University has passed the technical appraisal organized by Hebei Provincial Science and Technology Department and been concluded as internationally advanced by experts, which indicates a significant breakthrough in TCM treatment of polymyositis in China. 

Polymyositis is a specific autoimmune and inflammatory disease that involves mainly the striped muscle with cause unclear yet. It is characterized by such symptoms as symmetrical myasthenia of the limb proximal ends along with myalgia and/or muscle tendeness as well as muscular dystrophy in the late stage. The modern therapeutic methods include mainly application of glucocorticoid, immunosuppressant, plasma exchange and shock of gammaglobulin in treatment of polymyositis, which have predominant advantage for serious cases and those in acute stage, but their applications are restricted by the toxic or side effects. Considering the fact that there is no Chinese patent medicine in market for this disease so far, a project team led by Prof. Wu Yiling started the research of treating this disease with TCM as early as in 1990s. On the basis of traditional Chinese medical theories and medication against arthralgia syndrome and atrophic debilitys, Prof. Wu Yiling and et al believe through in-depth study that, polymyositis is caused by loss of nutrient in the Extraordinary Eight Meridians, sluggishness and deficiency of vital qi in the collaterals and collateral obstruction by evil factors. Therefore, it should be classified as numbness and atrophy type as per TCM theory and treated through eight extra channels as collateral disease. Accordingly, a therapeutic method is established to enhance the body resistance, treat atrophy, nourish skin, promote tissue regeneration, invigorate the spleen and tonify the kidney on the basis of expelling evil factors, removing numbness, dissolving stagnant and activating the channels. Accordingly, a TCM Jiyanling prescription was worked out and produced into TCM Jiyanling capsule against this disease strictly pursuant to technology and quality standard. 

For the purpose of validating the efficacy and mechanism of action further, the project team cooperated with Beijing University of Chinese Medicine on the experimental research of Jiyanling capsule in treatment of polymyositis, and the result turned out that Jiyanling capsule is efficacious in rectifying the clinical symptoms of EAM rats, improving their muscle strength, shortening the time limit of electromyogram, lowering wave amplitude, relieving impairment due to myogen, lowering the levels of creatase and anti-myosin antibody in sero, rectifying the manifestations of muscular pathology, inhibiting the lymphocytic proliferation of inguinal lymphnodes of EAM rats induced by ConA and Myosin in addition to inhibition of non-specific immune reaction. Besides, it indicated that both the high dose group and the medium dose group are superior to the prednisone group in inhibiting the proliferation of rat T lymphocyte induced by Myosin as well as rectifying electromyogram(high dose group). The pharmacodynamic study also implies that Jiyanling capsule adopts an immunoregulation mechanism in treatment of EAM, which is different from that of western medicines like steroids and immunosuppressants. And no evident toxic or side effect is found with Jiyanling capsule in toxicological examination. 

Jiyanling capsule has been clinically used for more than 10 years and has gained favorable effect. In order to evaluate the clinical effect of this drug objectively, a Jiyanling group, a prednisone group and a Jiyanling plus prednisone combined group were observed and compared. According to the result, the Jiyanling group does not differ significantly from the Prednisone control group in clinical effect score, decrease of creatase in sero and elevation of mean time limit as well as wave amplitude of electromyogram at the examined part. Either group above are inferior to the combined group in comprehensive treatment effect. Obvious excellence of Jiyanling group on the TCM symptoms improvement is observed, but no significant difference from the combined group. However, no side effect like increased fasting blood sugar, increased lipid level or central obesity is observed with the Jiyanling group, though they are found with the prednisone group. All these research results lead to a conclusion that Jiyanling capsule is a safe and effective TCM preparation against polymyositis. 

Nursing Knowledge of PM Patients
 I. Cares in Daily Life
1. In the acute stage, bed rest is suggested without active movement, but passive movement of joints and muscles, twice a day, is allowed to prevent myatrophy. 2. In the restoration stage, the patients are encouraged to exercise light movement appropriately, but neither too fast, nor too much. The exercise amount may increase gradually based on the resumption level of muscle strength. The patients should avoid overfatigue in functional training so as to prevent sero enzyme from elevation. 3. Keep the mind at ease and confidence in overcoming the disease. 

II. Diet Care
1．Arrange daily diets reasonably so as to guarantee sufficient intake of vitamin and protein. 
2．Avoid fatty and spicy foods as well as raw and cold foods so as to prevent impairing the liver's dampness-eliminating function. 
3. Herbal meals therapy dominated by invigorating the spleen and tonifying the kidney is suggested clinically. The TCM herbs that can be used in meals include Chinese yam(rhizoma dioscoreae), seed of jobstears, glabrous greenbrier rhizome, cordyceps,  angelica, wolferry fruit, ass hide, ganoderma lucidum, dried human placenta, ect. 

Precautions for Fighting against Dermatomyositis
1. Confidence and determination are needed in the first place. 
DM patients should make clear to themselves that this disease is not incurable and they never give up. It is not necessary to feel afraid or quit treatment for the disease is still in progress even after some traditional Chinese medicine and western medicine were administered. Nevertheless, it should be known well that dermatomyositis is truely a chronic and stubborn disease. It needs a firm faith and strong will power as well as optimistic altitude to invoke the potential resistance against disease and eventually overcome dermatomyositis. 

2. Long-term and proper treatment must be persisted. 
Dermatomyositis, as a chronic and stubborn disease, is not easy to be gotten rid of. It is the best way towards recovery to persist long-term, systematic, standard and reasonable treatment with the therapies combining TCM together with western medicine under the direction of a professional DM doctor who has abundant clinical experience and high sense of accountability. Never go to see uncertificated doctors, abuse of medicines, decrease the dosage of prescribed medicines or suspend the intake of medicine. Remember the old saying--"Fool's haste is no speed". It would be more difficult to treat once the disease recurs and become aggravated or even lead to death. 

3. Prevent infection. 
Bacteria, virus and mycotic infections are common and important inducing factors of dermatomyositis as well as common complications. Therefore, it is very important to prevent infections. Nourishment should be enhanced for patients and avoid adverse effects of such as low temperature. Appropriate physical exercise should be done so as to enhance resistance against infection. Besides, it is suggested to persist the treatment with both TCM and western medicines, use hormone and immunosuppressants reasonably so as to prevent serious infection. Timely and effective treatment must be given in case of infection so as to prevent undesirable result. 

4. Precautions in Daily Life
There are many factors in daily life that might render adverse effects to DM patients, which have to be given enough cares. For example, try to avoid sun exposure as much as possible, wear hat, glove and long-sleeve cloth in outdoor activities. Avoid or limit such foods as celery, daylily, lentinusedodes and others that enhance light sensitiveness or promoting immunologic function as well as the foods likely to induce allergy such as sea fish, shrimp and crab. Do not smoke or drink alcohol. Neither use lipstick, cosmetics or hair dye. Stay away from agricultural chemicals and chemical decorative materials. Female patients should try to avoid pregnancy and artificial abortion while the disease is not under control yet. Birth of baby must be given under the direction of doctor for female grown-up patients. Besides, enough sleep must be ensured, and avoid overfatigue and mental stress. Never do intensive movement. It is suggested to go for follow-up check regularly so as to become aware of the disease changes timely and adjust the medication as per doctor's instructions in accordance with the condition of diseases. For the cases that the disease state is stable or after suspension of the drug, it is suggested to receive follow-up check at least once in spring and autumn of every year respectively just for case.       

A Typical Case of Polymyositis
Ms.Liu, a 47-year-old farmer from Gucheng County, Hebei Province. She visited our department for hoarseness of voice, aphagia and myasthenia of limbs for one week and was diagnosed and hospitalized as polymyositis. 
The patient had such symptoms as hoarseness of voice, aphagia and myasthenia of limbs due to fatigue and emotional fluctuation one week ago. She was examined in the local hospital that the enzyme level of cardiac muscle elevated and the electromyogram indicated muscle-derived lesion, and diagnosed as polymyositis. She came to our hospital as per a friend's recommendation. 
Admission Physical Checkup: normal vital signs, but the patient looked suffering along with hoarseness, low voice,  no swallowing movement,Ⅱ grade of limb muscle strength, tendon reflex(＋), no pathologic reflex, pink tongue with yellowish thin coating, thready and rapid pulse. The double check confirmed the result of cardiac muscle enzyme and electromyogram made by the local hospital, and she was diagnosed as polymyositis. Nasal feeding tube was placed instantly to assure nourishment as well as maintenance of water and electrolyte balance; meanwhile, as TCM treatment, she was administered 3g Jiyanling Medicinal Granule, 5g Jiyanling No.2 and 250ml TCM medical broth for warming yang and supplementing qi through the nasal feeding tube, 3 times a day. Intravenous transfusion:  Benzylpenicillin 8,000,000 units, carulon (dexamethasone) 10mg, 1 shot/day, decreased dosage gradually. 
After one month's treatment in hospital, her conditions were improved markedly in mental state and physical strength with such symptoms as hoarseness and aphagia disappeared,  and able to conduct indoor activities off the bed. Carulon dosage: reduced to 5mg/day; 8,000,000 units of Benzylpenicillin was replace with 32ml Jiweiling Injection, i.v., 1 shot/day; 4g Jiyanling medicinal powder, 3 times/day;  5g Jiyanling No.5, 3 times/day and Jiyanling No.7, 4 capsule, 3 times/day.
After three months' hospitalization, the patient was able to go downstairs independently and stand up after crouching. At that time when the dose of prednisone was reduced to 15mg/day, the disease was stable and the patient getting better day by day. She went back home for continual treatment with the medicines prescribed by our hospital. After three more months, she was said able to do farming works as usual when one of her family numbers paid a return visit to our hospital. To consolidate the effect, she was administered 5g Jiyanling No.5, once/day, and 5mg prednisone, once every other day. Until today, her disease is stable and no recurrence.