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[Anti-Neutrophil Cytoplasmic Antigens (ANCA)-associated vasculitis: Current therapeutics]
1Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France.
Insights
Rituximab is the most effective maintenance therapy for ANCA-associated vasculitis, outperforming methotrexate and azathioprine. For Eosinophilic Granulomatosis with Polyangiitis, mepolizumab helps prevent relapses and reduce corticosteroid dependence.
Area of Science:
- Rheumatology
- Immunology
- Internal Medicine
Background:
- ANCA-associated vasculitis encompasses granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis.
- Significant therapeutic advances have occurred over the past three decades, including targeted therapies.
- Treatment involves induction and maintenance phases, with induction generally well-managed.
Purpose of the Study:
- To evaluate the efficacy of different maintenance treatments for ANCA-associated vasculitis.
- To assess the role of rituximab, methotrexate, azathioprine, and mepolizumab in managing these conditions.
- To address current questions regarding maintenance treatment duration and risks of immunosuppression.
Main Methods:
- The study highlights established induction protocols combining corticosteroids with rituximab or cyclophosphamide.
- Comparative efficacy of maintenance therapies, including rituximab, methotrexate, and azathioprine, was investigated.
- Specific considerations for Eosinophilic Granulomatosis with Polyangiitis (GEPA) and the role of mepolizumab were examined.
Main Results:
- Rituximab demonstrated superior efficacy as a maintenance treatment compared to methotrexate or azathioprine.
- In GEPA, mepolizumab showed promise in preventing relapses and enabling corticosteroid dose reduction for asthma control.
- Induction therapy typically achieves remission within six months.
Conclusions:
- Rituximab is the preferred maintenance therapy for ANCA-associated vasculitis, minimizing relapse risk.
- Mepolizumab offers a valuable option for GEPA maintenance, particularly for managing asthma and reducing steroid burden.
- Future research should focus on optimizing maintenance treatment duration and mitigating long-term immunosuppression risks, such as infections.
Abstract:
ANCA-associated vasculitis brings together three diseases, granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. This group of diseases has benefited over the last 3 decades from major therapeutic advances both in terms of therapeutic strategies and availability of new drugs, mainly for targeted therapies. Treatments, whether conventional or not, include an induction phase followed by a maintenance phase. Induction treatment today poses few problems. It is essentially based on the combination of corticosteroids and rituximab or cyclophosphamide. Remission is achieved in less than 6 months and maintenance treatment, preventing relapses, is then started. We showed that the best maintenance treatment was rituximab, surpassing the efficacy of methotrexate or azathioprine. During this phase, corticosteroid therapy is stopped or given at a very small dose. In Eosinophilic Granulomatosis with Polyangiitis (GEPA), the strategy is slightly different and there is a lack of prospective trials to demonstrate the benefits of rituximab or mepolizumab (anti-IL5) in inducing remission. Regarding maintenance treatment, prolonged corticosteroid therapy (orally and/or inhaled) is often necessary to control asthmatic disease. Only mepolizumab has shown its ability to prevent relapses and reduce the dose of corticosteroids controlling asthma. The current questions posed by maintenance treatment are its duration which could be variable and adapted to the risk of relapse and the risks induced by prolonged immunosuppression, particularly infectious.
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