☆ 4.5 Article

Outcomes of Nonsevere Relapses in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Treated With Glucocorticoids

ARTHRITIS & RHEUMATOLOGY (2015)

Journal

ARTHRITIS & RHEUMATOLOGY

Volume 67, Issue 6, Pages 1629-1636

Publisher

WILEY-BLACKWELL

DOI: 10.1002/art.39104

Keywords

Funding

Immune Tolerance Network (NIH) [N01-AI-15416, ITN021AI]
National Institute of Allergy and Infectious Diseases, NIH
Juvenile Diabetes Research Foundation
Genentech
Biogen Idec
NIH (Mayo Clinic: National Center for Research Resources Clinical and Translational Science award) [1-UL1-RR-024150-01]
NIH (Johns Hopkins University: National Center for Research Resources Clinical and Translational Science) [UL1-RR-025005, K23-AR-052820, K24-AR-049185]
NIH (Boston University: National Center for Research Resources Clinical and Translational Science) [UL1-RR-025771, M01-RR-00533, K24-AR-02224]
NIH (Cleveland Clinic: National Center for Advancing Translational Sciences) [UL1-TR-000439]
Arthritis Foundation
ChemoCentryx
GlaxoSmithKline
Eli Lilly
MedImmune

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Abstract

Objective. Nonsevere relapses are more common than severe relapses in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), but their clinical course and treatment outcomes remain largely unexamined. We undertook this study to analyze the outcomes of patients with nonsevere relapses in the Rituximab in ANCA-Associated Vasculitis (RAVE) trial who were treated with prednisone according to a prespecified protocol. Methods. RAVE was a randomized, double-blind, placebo-controlled trial comparing rituximab (RTX) to cyclophosphamide (CYC) followed by azathioprine (AZA) for induction of remission. Patients who experienced nonsevere relapses between months 1 and 18 were treated with a prednisone increase without a concomitant change in their nonglucocorticoid immunosuppressants, followed by a taper. Results. Forty-four patients with a first nonsevere relapse were analyzed. In comparison to the 71 patients who maintained relapse-free remission over 18 months, these patients were more likely to have proteinase 3-ANCAs, diagnoses of granulomatosis with polyangiitis (Wegener's), and a history of relapsing disease at baseline. A prednisone increase led to remission in 35 patients (80%). However, only 13 patients (30%) were able to maintain second remissions through the followup period (mean 12.5 months); 31 patients (70%) had a second disease relapse, 14 of them with severe disease. The mean time to second relapse was 9.4 months (4.7 months in the group treated with RTX versus 13.7 months in the group treated with CYC/AZA; P<0.01). Patients who experienced nonsevere relapses received more glucocorticoids than those who maintained remission (6.7 grams versus 3.8 grams; P<0.01). Conclusion. Treatment of nonsevere relapses in AAV with an increase in glucocorticoids is effective in restoring temporary remission in the majority of patients, but recurrent relapses within a relatively short interval remain common. Alternative treatment approaches are needed for this important subset of patients.

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Clinical Practice Audit on the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis in the Netherlands

Ebru Dirikgil, Jacqueline T. Jonker, Sander W. Tas, Cornelis A. Verburgh, Darius Soonawala, A. Elisabeth Hak, Hilde H. F. Remmelts, Daphne IJpelaar, Gozewijn D. Laverman, Abraham Rutgers, Jacob M. van Laar, Hein J. Bernelot Moen, Peter M. J. Verhoeven, Ton J. Rabelink, Willem Jan W. Bos, Y. K. Onno Teng

Summary: The study investigated the real-life management and outcomes of AAV patients in the Netherlands, revealing oral cyclophosphamide as the most frequently used induction therapy, azathioprine for maintenance therapy, and an increasing use of rituximab over time. Major infection and relapses were found to be the most prevalent adverse outcomes. This audit provided important indicators for the treatment of AAV patients that can be implemented in future national audits to improve patient outcomes.

KIDNEY INTERNATIONAL REPORTS (2021)