Conventional and biological immunosuppressants in vasculitis

The following chapter outlines the main findings from clinical trials, which provide information on the current best evidence-based management of the myriad of conditions that comprise vasculitis. Glucocorticoids (GCs) have been the mainstay of treatment of large-vessel vasculitis since Birkhead et al. used intramuscular cortisone daily and obtained good results in patients with giant cell arteritis. Recent trial data offer the hope that future treatment regimens may not need to be quite reliant on steroids. The use of GCs remains central to the management of many of the vasculitides, but recent advances owing to well run and coordinated clinical trials are changing the management approach. The strategy of aggressive induction of remission followed by a period of maintenance therapy has been established for patients with anti-neutrophil cytoplasm antibody-associated vasculitis. It remains unclear whether prediction can be made regarding which presentations or phenotypes should be treated with which drug regimen and when patients are likely to relapse. Currently, maintenance therapy is indicated for 2 years but whether there can be better tailored strategies remains to be proven. This chapter focuses on the main types of vasculitis, describing first the evidence for conventional immunosuppressants and then evidence for the use of biologics. Non-pharmacologic approaches are discussed in the next chapter.