What is the most appropriate next step in management for a patient with dermatomyositis who is maintained on methotrexate 25 mg weekly but develops disease flare when prednisone is tapered below 10 mg daily and is unable to receive IVIG?

The fact that the patient cannot taper prednisone below 10 mg indicates that methotrexate alone, while has some effect, is not sufficient to control the disease. There are several options, depending on the severity of each organ involvement. Since the joints are affected, I would favor an agent that...

The main question is what flare is about - skin rash, muscle weakness, ILD, etc., and the next steps are sometimes dependent on it. If skin or muscle, then would recommend adding mycophenolate. If ILD or even for muscle, perhaps going to rituximab or adding tacrolimus. Skin also responds to JAK inhi...