Avacopan, rituximab allow for reduced glucocorticoid use in ANCA-associated vasculitis
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SAN DIEGO — In patients with ANCA-associated vasculitis, avacopan and rituximab may offer an alternative to glucocorticoids-based management, according to a presenter at the Congress of Clinical Rheumatology West.
“We are seeing a reduced use of glucocorticoids, both because we do not need to use as much and because we have newer agents that are allowing even more intense reduction of glucocorticoid use,” Kenneth J. Warrington, MD, a professor of medicine at the Mayo Clinic College of Medicine and Science, and chair of the division of rheumatology at the Mayo Clinic, told attendees. “Rituximab has really kept its central role for remission induction as well as for maintenance of remission.”
According to Warrington, ultimate goal of ANCA-associated vasculitis (AAV) management can range from keeping the patient alive to improving their quality of life whenever possible.
“Untreated AAV has a mortality rate approaching 90%,” he said. “First, we want to induce remission to limit organ damage and then to ensure patient survival, and eventually we want to maintain remission and manage relapses.”
It is also important for rheumatologists to monitor and minimize the amount of treatment-related toxicity through reduced reliance on glucocorticoids, Warrington said.
Although it does not entirely eliminate the need for glucocorticoids, avacopan (Tavneos, Chemocentryx) can help in this regard. The drug works in conjunction with rituximab (Rituxan, Genentech) or cyclophosphamide.
According to Warrington, patients who will benefit most from the introduction of avacopan are those experiencing, or at risk for, glucocorticoid toxicity, as well as those with renal failure. After the initiation, the glucocorticoid should be tapered over 4 weeks, he added.
“There is some glucocorticoid use with the drug,” Warrington said. “It is not approved as being a glucocorticoid replacement, entirely, but it is a glucocorticoid-sparing drug.”
He also recommended monitoring liver function every 4 weeks for a total of 6 months, and then as indicated.
According to Warrington, rheumatologists treating patients with AAV face a serious dilemma, teetering between the risk for relapse and causing toxicity due to disease maintenance. When managing this risk, Warrington recommended assessing factors that may predict disease relapse, including a diagnosis of granulomatosis with polyangiitis, “persistently positive” ANCA titers, previous relapse and the involvement of the upper respiratory tract in the disease.
“There is a cost factor, but it is approved, and I think we will accumulate more experience with this drug,” he said. “It is an exciting time in the management of patients with AAV, especially as other complimentary inhibitors are being looked at in this disease.”
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Warrington KJ. ANCA-associated vasculitis update. Presented at The Congress of Clinical Rheumatology West; Oct. 20-23, 2022 (hybrid meeting).
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