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Emerging Treatments Presented for Relapsing Vasculitis
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DESTIN, Fla. — At the Congress of Clinical Rheumatology Annual Meeting, Gary S. Hoffman, MD, MS, MACR, professor emeritus at the Center for Vasculitis Care and Research, Cleveland Clinic Foundation, Lerner College of Medicine, presented emerging evidence on the prevention and treatment of relapsing vasculitis.
“We wanted to use the best available data to define [antineutrophil cytoplasmic antibodies] ANCA-associated vasculitis [AAV] and formulate a perspective on why that term misinforms study design and should be abandoned,” he said. “Also, we wanted to see how we could minimize or avoid long-term cyclophosphamide [CYC] and discuss the impact and limitations of rituximab [RTX] therapy.”
Gary S. Hoffman
Hoffman and a team of researchers performed a systematic review to categorize AAV into the following three types: granulomatosis with polyangiitis (GPA); microscopic polyangiitis (MPA); and eosinophilic granulomatosis with polyangiitis (EGPA). Each targets vessels, but differ substantially, Hoffman said. “Clinical trials that consider AAV as one single entity must be interpreted carefully, since subsets may respond differently to therapeutic intervention.”
After investigation, researchers determined that when treated with CYC, GPA and MPA patients saw high levels of remission, but Hoffman warned that extended CYC use should be avoided.
He added RTX should be considered in patients of reproductive age and those who have received CYC in the past with severe relapse. Maintenance therapy should be considered in patients with prior RTX-mediated remission and who have had severe critical organ damage.
“Long-term maintenance therapy that is well tolerated results in greater duration of sustained remission and should be continued,” Hoffman said. “Doses should be individualized based on tolerance.”
Researchers also noted use of interluekin-5 in EPGA activates and amplifies eosinophils production in bone marrow, which could lead to prolonged survival.
“We now have the ability to achieve and sustain remissions more safely and have dramatically reduced [serious adverse events] SAEs, in GPA and MPA particularly,” Hoffman said. “Chronic, long-term CYC therapy is no longer justified.” Limited CYC use continues to be life-saving, he added, and RTX is a preferred treatment in several settings.
With emerging data in the treatment of AAV, arbitrarily discontinuing well-tolerated maintenance therapy in life-threating, incurable diseases may be ill-advised, Hoffman said, adding that researchers will continue to explore new ways to treat relapsing vasculitis. – by Shawn M. Carter
Reference:
Hoffman G, et al. Prevention and treatment of relapsing vasculitis. Presented at: Congress of Clinical Rheumatology Annual Meeting; May 12-15, 2015; Destin, Fla.
Disclosure: Hoffman reports no relevant financial disclosures.