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Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 124] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Roccatello D, Padoan R, Sciascia S, Iorio L, Nic An Ríogh E, Little MA. Might maintenance therapy be discontinued once clinical remission is achieved in ANCA-associated vasculitis? Autoimmun Rev 2024; 23:103438. [PMID: 37652397 DOI: 10.1016/j.autrev.2023.103438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) encompasses a group of rare, multisystem autoimmune disorders characterised by the occurrence of inflammation and damage to small blood vessels, leading to a wide range of clinical manifestations. They include granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Outcomes for patients with MPA and GPA have been transformed over recent years. However, the establishment of effective maintenance therapy aiming to balance the risks of disease relapse with those related to prolonged immunosuppression has become a clinical priority. This review aims to explore two differing perspectives on this unsolved problem. Pros and Cons of the following approaches will be discussed: "Biomarker-guided personalised approach on top of generic maintenance strategy guidelines" or "ANCA specificity-related personalised maintenance treatment after intensive B-cell depletion"?
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Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnet and ERN-RITA Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, ASL Città di Torino and University of Torino, Turin, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy.
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnet and ERN-RITA Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, ASL Città di Torino and University of Torino, Turin, Italy
| | - Luca Iorio
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Eithne Nic An Ríogh
- Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College, Dublin, Ireland
| | - Mark A Little
- Trinity Kidney Centre, Trinity Translational Medicine Institute, School of Medicine, Trinity College, Dublin, Ireland
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3
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Schuster DD, Gillis D, Wong RCW, Kodituwakku A, Droney L, Ranganathan D. Anti-neutrophil cytoplasmic antibody monitoring in vasculitis patients to predict relapse. Int J Rheum Dis 2023; 26:1861-1865. [PMID: 37183714 DOI: 10.1111/1756-185x.14728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/05/2023] [Accepted: 04/29/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Daniel D Schuster
- University of Queensland, Brisbane, Queensland, Australia
- Pathology Queensland, Brisbane, Queensland, Australia
| | - David Gillis
- Pathology Queensland, Brisbane, Queensland, Australia
| | | | | | - Luke Droney
- University of Queensland, Brisbane, Queensland, Australia
- Pathology Queensland, Brisbane, Queensland, Australia
| | - Dwarakanathan Ranganathan
- Kidney Health Services, Metro North Hospital and Health Services, Brisbane, Queensland, Australia
- Griffith School of Medicine and Dentistry, Gold Coast, Queensland, Australia
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Wallace ZS, Stone JH, Fu X, Merkel PA, Miloslavsky EM, Zhang Y, Choi HK, Hyle EP. Development and Validation of a Simulation Model for Treatment to Maintain Remission in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2023; 75:1976-1985. [PMID: 36645017 PMCID: PMC10349892 DOI: 10.1002/acr.25088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 12/08/2022] [Accepted: 01/10/2023] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Fixed and tailored rituximab retreatment strategies to maintain remission in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are associated with tradeoffs. The current study was undertaken to develop a simulation model (AAV-Sim) to project clinical outcomes with these strategies. METHODS We developed the AAV-Sim, a microsimulation model of clinical events among individuals with AAV initiating treatment to maintain remission. Individuals transition between health states of remission or relapse and are at risk for severe infection, end-stage renal disease, or death. We estimated transition rates from published literature, stratified by individual-level characteristics. We performed validation using the mean average percent error (MAPE) and the coefficient of variation of root mean square error (CV-RMSE). In internal validation, we compared model-projected outcomes over 28 months with outcomes observed in the Rituximab versus Azathioprine in ANCA-Associated Vasculitis 2 (MAINRITSAN2) trial, which compared fixed versus tailored retreatment. In external validation, we compared outcomes with fixed rituximab retreatment from the AAV-Sim to outcomes from the MAINRITSAN1 trial and an observational study. RESULTS The AAV-Sim projected outcomes similar to those in the MAINRITSAN2 trial, including minor (AAV-Sim 6.0% fixed versus 7.3% tailored; MAINRITSAN2 6.2% versus 8.6%; MAPE 3% and 15%) and major relapse (AAV-Sim 3.5% versus 5.5%; MAINRITSAN2 3.7% versus 7.4%; MAPE 5% and 26%), severe infection (AAV-Sim 19.4% versus 11.1%; MAINRITSAN2 19.8% versus 10.2%; MAPE 2% and 9%), and relapse-free survival (AAV-Sim 84.8% versus 82.3%; MAINRITSAN2 86% versus 84%; CV-RMSE 2.3% and 2.5%). Similar performance was observed in external validation. CONCLUSION The AAV-Sim projected a range of clinical outcomes for different treatment approaches that were validated against published data. The AAV-Sim has the potential to inform management guidelines and research priorities.
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Affiliation(s)
- Zachary S. Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | - John H. Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
| | - Peter A. Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Eli M. Miloslavsky
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | - Hyon K. Choi
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | - Emily P. Hyle
- Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA
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Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
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Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
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Puéchal X, Guillevin L. How best to manage relapse and remission in ANCA-associated vasculitis. Expert Rev Clin Immunol 2022; 18:1135-1143. [PMID: 36102147 DOI: 10.1080/1744666x.2022.2122954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION A 2-stage therapeutic approach is now applied as standard-of-care to treat ANCA-associated vasculitides (AAVs): first, glucocorticoids (GCs) combined with cyclophosphamide (CYC) or rituximab (RTX) to induce remission, then relapse prevention with remission-maintenance therapy. Nonetheless, a substantial risk of relapse persists. AREAS COVERED The authors provide an overview of the current state of maintenance therapies, and discuss new strategies recommended to prevent and treat relapses, focusing on granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). EXPERT OPINION For remission-induction after GPA or MPA relapse with organ-threatening manifestations, reintroduction or intensification of the GC dose in combination with CYC or RTX cycle is recommended; we prefer RTX in light of its superior responses obtained in patients with relapsing disease. Rapid tapering of GCs has been shown not to alter AAV evolution while decreasing the risk of serious infections. In contrast, for non-severe, active MPA, we recommend GCs alone as first-line therapy. For patients whose MPA remains uncontrolled by GCs alone, immunosuppressant adjunction can be a GC-sparing option or to counter GC intolerance. Once remission is achieved, we recommend prolonged maintenance therapy with preemptive low-dose (500 mg) RTX infusion biannually.
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Affiliation(s)
- Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP).Centre, Université Paris Cité, Paris, France.,French Vasculitis Study Group, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP).Centre, Université Paris Cité, Paris, France.,French Vasculitis Study Group, Hôpital Cochin, Paris, France
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Monach PA, Warner RL, Lew R, Tómasson G, Specks U, Stone JH, Fervenza FC, Hoffman GS, Kallenberg CGM, Langford CA, Seo P, St Clair EW, Spiera R, Johnson KJ, Merkel PA. Serum Biomarkers of Disease Activity in Longitudinal Assessment of Patients with ANCA-Associated Vasculitis. ACR Open Rheumatol 2021; 4:168-176. [PMID: 34792864 PMCID: PMC8843765 DOI: 10.1002/acr2.11366] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/01/2021] [Accepted: 09/13/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Improved biomarkers of current disease activity and prediction of relapse are needed in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). For clinical relevance, biomarkers must perform well longitudinally in patients on treatment and in patients with nonsevere flares. METHODS Twenty-two proteins were measured in 347 serum samples from 74 patients with AAV enrolled in a clinical trial. Samples were collected at Month 6 after remission induction, then every 3 months until Month 18, or at the time of flare. Associations of protein concentrations with concurrent disease activity and with future flare were analyzed using mixed-effects models, Cox proportional hazards models, and conditional logistic regression. RESULTS Forty-two patients had flares during the 12-month follow-up period, and 32 remained in remission. Twenty-two patients had severe flares. Six experimental markers (CXCL13, IL-6, IL-8, IL-15, IL-18BP, and matrix metalloproteinase-3 [MMP-3]) and ESR were associated with disease activity using all three methods (P < 0.05, with P < 0.01 in at least one method). A rise in IL-8, IL-15, or IL-18BP was associated temporally with flare. Combining C-reactive protein (CRP), IL-18BP, neutrophil gelatinase-associated lipocalin (NGAL), and sIL-2Rα improved association with active AAV. CXCL13 and MMP-3 were increased during treatment with prednisone, independent of disease activity. Marker concentrations during remission were not predictive of future flare. CONCLUSION Serum biomarkers of inflammation and tissue damage and repair have been previously shown to be strongly associated with severe active AAV were less strongly associated with active AAV in a longitudinal study that included mild flares and varying treatment. Markers rising contemporaneously with flare or with an improved association in combination merit further study.
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Affiliation(s)
- Paul A Monach
- Boston University, Boston, Massachusetts.,VA Boston Healthcare System, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Robert Lew
- Boston University, Boston, Massachusetts
| | | | | | - John H Stone
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
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[High burden of disease in patients with ANCA-associated vasculitis : A claims data study in Germany]. Internist (Berl) 2021; 63:210-216. [PMID: 34665272 PMCID: PMC8813869 DOI: 10.1007/s00108-021-01181-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/22/2022]
Abstract
Hintergrund und Zielsetzung Unter dem Begriff der mit antineutrophilen zytoplasmatischen Antikörpern (ANCA) assoziierten Vaskulitis (AAV) wird eine Gruppe seltener, chronischer, durch rezidivierende systemische Entzündungen gekennzeichneter Autoimmunerkrankungen mit vielfältigen Morbiditäten zusammengefasst. Patienten mit AAV leiden unter diversen Organmanifestationen und schweren Nebenwirkungen der Therapie. In dieser retrospektiven Studie wurde die konkrete Belastung der Patienten durch die AAV-Erkrankung in Deutschland untersucht. Methodik Basierend auf anonymisierten Längsschnittdaten der gesetzlichen Krankenversicherung (GKV) zur medizinischen Versorgung zwischen 2013 und 2016 wurden aus einer repräsentativen Kohorte von etwa 3 Mio. Versicherten Patienten mit Granulomatose mit Polyangiitis (GPA) und mikroskopischer Polyangiitis (MPA) identifiziert und ausgewählte klinische Aspekte systematisch analysiert. Ergebnisse Die häufigsten begleitenden Morbiditäten von GPA und MPA waren Nieren- und Atemwegserkrankungen. Eine schwere Nierenbeteiligung trat bei 11,6 % der GPA- und 24,3 % der MPA-Patienten innerhalb von 15 Quartalen nach der Diagnose auf. Bei einem Drittel der Patienten mit AAV entwickelten sich innerhalb der ersten 3 Quartale nach Diagnose schwere Infektionen. Die Rate der schweren Rezidive betrug jährlich 5–8 %. Patienten mit AAV und Nierenbeteiligung oder Infektionen zeigten zudem eine hohe jährliche Mortalitätsrate von 14,4 % bzw. 5,6 %. Schlussfolgerung Anhand dieser Analyse deutscher Versorgungsdaten wurden krankheitsspezifische Annahmen der Belastung von Patienten mit AAV bestätigt und für den deutschen Kontext konkretisiert. Patienten mit AAV leiden unter einer hohen Morbiditätsbelastung, einschließlich multipler Krankheitsmanifestationen, Rezidiven und schwerer Komplikationen aufgrund der AAV-Therapie. Zusatzmaterial online Die Online-Version dieses Beitrags (10.1007/s00108-021-01181-z) enthält eine zusätzliche Tabelle sowie zwei weitere Abbildungen.
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Thompson GE, Fussner LA, Hummel AM, Schroeder DR, Silva F, Snyder MR, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Stone JH, Specks U. Clinical Utility of Serial Measurements of Antineutrophil Cytoplasmic Antibodies Targeting Proteinase 3 in ANCA-Associated Vasculitis. Front Immunol 2020; 11:2053. [PMID: 33013868 PMCID: PMC7495134 DOI: 10.3389/fimmu.2020.02053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The utility of ANCA testing as an indicator of disease activity in ANCA-associated vasculitis (AAV) remains controversial. This study aimed to determine the association of ANCA testing by various methods and subsequent remission and examine the utility of a widely used automated addressable laser-bead immunoassay (ALBIA) to predict disease relapses. Methods: Data from the Rituximab vs. Cyclophosphamide for ANCA-Associated Vasculitis (RAVE) trial were used. ANCA testing was performed by direct ELISA, capture ELISA, and ALBIA. Cox proportional hazards regression models were used to evaluate the association of PR3-ANCA level and subsequent remission or relapse. The ALBIA results are routinely reported as >8 when the value is high. For this study, samples were further titrated. A decrease and increase in PR3-ANCA were defined as a halving or doubling in value, respectively. Results: A decrease in ANCA by ALBIA at 2 months was associated with shorter time to sustained remission (HR 4.52, p = 0.035). A decrease in ANCA by direct ELISA at 4 months was associated with decreased time to sustained remission (HR 1.77, p = 0.050). There were no other associations between ANCA decreases or negativity and time to remission. An increase in PR3-ANCA by ALBIA was found in 78 of 93 subjects (84%). Eleven (14%) had a PR3-ANCA value which required titration for detection of an increase. An increase of ANCA by ALBIA was associated with severe relapse across various subgroups. Conclusions: A decrease in ANCA by ALBIA at 2 months and by direct ELISA at 4 months may be predictive of subsequent remission. These results should be confirmed in a separate cohort with similarly protocolized sample and clinical data collection. A routinely used automated ALBIA for PR3-ANCA measurement is comparable to direct ELISA in predicting relapse in PR3-AAV. Without titration, 14% of the increases detected by ALBIA would have been missed. Titration is recommended when this assay is used for disease monitoring. The association of an increase in PR3-ANCA with the risk of subsequent relapse remains complex and is affected by disease phenotype and remission induction agent.
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Affiliation(s)
- Gwen E Thompson
- Essentia Health, Division of Pulmonary and Critical Care, Fargo, ND, United States.,Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Amber M Hummel
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Darrell R Schroeder
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Francisco Silva
- Department of Rheumatology, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Melissa R Snyder
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
| | - Carol A Langford
- Cleveland Clinic, Division of Rheumatology, Cleveland, OH, United States
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, United States
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, United States
| | - Robert F Spiera
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, United States
| | | | - John H Stone
- Division of Rheumatology, Massachusetts General Hospital, Boston, MA, United States
| | - Ulrich Specks
- Mayo Clinic and Mayo Foundation for Research and Education, Rochester, MN, United States
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10
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Masiak A, Fijałkowska J, Nowakowski S, Smoleńska Ż, Zdrojewski Z. New lung mass in a patient with granulomatosis with polyangiitis. Rheumatol Int 2020; 41:493-499. [PMID: 32671469 PMCID: PMC7835303 DOI: 10.1007/s00296-020-04646-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/03/2020] [Indexed: 12/19/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a potentially lethal ANCA-associated small-vessel vasculitis characterized by a typical triad of upper respiratory tract, lung, and kidney involvement. Lung involvement in GPA occurs in 25–80% of cases. The most common radiographic and computed tomography (CT) abnormalities of pulmonary GPA are lung nodules and masses, very often multiple and with cavitation. As there are various clinical presentations, the diagnosis of GPA can be challenging, and the illness is difficult to distinguish from other diseases such as infection or malignancy. Following the improved survival rates in patients with GPA, there is accumulating evidence to suggest an increased occurrence of different types of cancer. Exposure to cyclophosphamide seems to be one of its main causes. We present the case of a patient with chronic GPA who was hospitalized owing to a new infiltrate in the lung, suggesting relapse of the disease, and finally diagnosed with small cell lung cancer. Data regarding lung cancer in GPA patients are limited. While there are some case reports and short case series in the literature, there are no detailed data regarding an association between CYC exposure and lung cancer development in vasculitis. It is necessary to consider the causes of pulmonary masses other than a GPA relapse. Bronchoscopy with biopsy and histopathological examination are crucial in proper differential diagnosis. GPA patients require long-term follow-up to monitor for the development of complications during treatment.
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Affiliation(s)
- Anna Masiak
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, ul. Dębinki 7, 80-952, Gdansk, Poland.
| | - Jadwiga Fijałkowska
- Second Department of Radiology, Medical University of Gdansk, Gdansk, Poland
| | - Szymon Nowakowski
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, ul. Dębinki 7, 80-952, Gdansk, Poland
| | - Żaneta Smoleńska
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, ul. Dębinki 7, 80-952, Gdansk, Poland
| | - Zbigniew Zdrojewski
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, ul. Dębinki 7, 80-952, Gdansk, Poland
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ANCA-associated vasculitides: Recommendations of the French Vasculitis Study Group on the use of immunosuppressants and biotherapies for remission induction and maintenance. Presse Med 2020; 49:104031. [PMID: 32645418 DOI: 10.1016/j.lpm.2020.104031] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/21/2020] [Indexed: 12/13/2022] Open
Abstract
Treatment of vasculitides associated with anti-neutrophil cytoplasm antibodies (ANCA) (AAVs) has evolved dramatically in recent years, particularly since the demonstration of rituximab efficacy as remission induction and maintenance therapy for granulomatosis with polyangiitis and microscopic polyangiitis. In 2013, the French Vasculitis Study Group (FVSG) published recommendations for its use by clinicians. Since then, new data have made it possible to better specify and codify prescription of rituximab to treat AAVs. Herein, the FVSG Recommendations Committee, an expert panel comprised of physicians with extensive experience in the treatment and management of vasculitides, presents its consensus guidelines based on literature analysis, the results of prospective therapeutic trials and personal experience.
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Abstract
INTRODUCTION Rituximab, an anti-B-cell biological therapy, has been investigated in several clinical trials on antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). AREAS COVERED In this paper, the clinical trials and open-label studies on rituximab efficacy and safety in treating AAVs are reviewed. EXPERT OPINION Rituximab achieved high remission-induction and sustained-maintenance rates for patients with these severe diseases, thereby challenging the cornerstone treatment of corticosteroids and cyclophosphamide followed by azathioprine. Rituximab should be used as first-line therapy with corticosteroids to induce remission of severe AAVs, especially in situations in which cyclophosphamide may be problematic (relapse after cyclophosphamide, women of childbearing age, risk of malignancy). Cyclophosphamide indications are likely to be restricted in the future. Whenever possible, rituximab should be preferred to azathioprine to maintain remission. The current maintenance regimen has been extended to at least 18 months but its optimal duration remains unknown and recent data suggest the possibility to extend treatment to 4 years. Future challenges include defining the best dose regimen: at present, different schedules are used as alternatives to those recognized as standards by health authorities. In addition, it remains to identify which patients will benefit the most from long-term retreatment: potentially those with relapsing disease or anti-proteinase-3 ANCA-positivity.
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Affiliation(s)
- Loïc Raffray
- Department of Internal Medicine, Félix-Guyon University Hospital of La Réunion , Saint-Denis, France
| | - Loïc Guillevin
- Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Université Paris Descartes , Paris, France
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13
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Outh R, Lemaire A, Mania A, Berland P, Gerbaud L, Aumaître O, André M. Relapses in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis: a retrospective study. Clin Rheumatol 2020; 39:1601-1608. [PMID: 31907693 DOI: 10.1007/s10067-019-04816-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/30/2019] [Accepted: 10/10/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To investigate the activity of relapsing events (RE) and their mode of presentation in patients with anti-neutrophil cytoplasmic (ANCA)-associated vasculitis (AAV). METHODS Patients diagnosed with AAV between 1990 and 2015 experiencing at least one RE were investigated. The different organ involvements were registered during each RE. Presentation at initial onset (IO) and RE were compared. The Birmingham Vasculitis Activity Score was used to assess the activity. RESULTS Ninety-nine patients were followed: 54 patients with 96 RE and 45 patients with none. The rate of RE was 53% with a median time of follow-up of 6.8 years. The mean time to first RE was 2.8 years. Thirty patients experienced one single RE, 15 had 2, 5 had 3, 2 had 4, and 2 had, respectively, 7 and 8. Fifty-five percent of RE had the same features as IO. Compared to IO, some clinical manifestations were less present: constitutional symptoms (29% vs 69%), ear-nose-throat (50% vs 76%), lung involvement (59% vs 76%), peripheral neuropathies (14% vs 24%), arthritis (7% vs 27%), kidney (25% vs 41%), and heart (4% vs 20%) (p < 0.001). Skin, eye, and bowel manifestations were not significantly less involved during RE. The mean Birmingham Vasculitis Activity Score at IO was 9.02 and 5.11 at relapse (p < 0.0001). Among the 96 RE, 46% had a new organ involvement compared to IO: none were life-threatening. CONCLUSION Global activity of RE in AAV patients is lower than that of IO. Fewer organs are involved in relapses. RE turned out to begin with the same manifestations as IO in most cases.Key Points•First study looking into clinical characteristics of relapses including mostly granulomatosis with polyangiitis.•Around half of patients with AAV seemed to relapse in a similar way compared to the initial diagnosis.•The activity score during relapsing events is less important.
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Affiliation(s)
- Roderau Outh
- Service de Médecine Interne, Centre Hospitalier Universitaire, Hôpital Gabriel-Montpied, 58 rue Montalembert, 63003, Clermont-Ferrand, France.
| | - Anne Lemaire
- Service de Médecine Interne, Centre Hospitalier Universitaire, Hôpital Gabriel-Montpied, 58 rue Montalembert, 63003, Clermont-Ferrand, France
| | - Alexandre Mania
- Service de Médecine Interne, Centre Hospitalier Universitaire, Hôpital Gabriel-Montpied, 58 rue Montalembert, 63003, Clermont-Ferrand, France
| | - Pauline Berland
- Service de Santé Publique, Centre Hospitalier Universitaire, Hôpital Gabriel-Montpied, Clermont-Ferrand, France
| | - Laurent Gerbaud
- Service de Santé Publique, Centre Hospitalier Universitaire, Hôpital Gabriel-Montpied, Clermont-Ferrand, France
| | - Olivier Aumaître
- Service de Médecine Interne, Centre Hospitalier Universitaire, Hôpital Gabriel-Montpied, 58 rue Montalembert, 63003, Clermont-Ferrand, France
| | - Marc André
- Service de Médecine Interne, Centre Hospitalier Universitaire, Hôpital Gabriel-Montpied, 58 rue Montalembert, 63003, Clermont-Ferrand, France
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14
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Imbalance of Circulatory T Follicular Helper and T Follicular Regulatory Cells in Patients with ANCA-Associated Vasculitis. Mediators Inflamm 2019; 2019:8421479. [PMID: 31885499 PMCID: PMC6914973 DOI: 10.1155/2019/8421479] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/20/2019] [Accepted: 08/29/2019] [Indexed: 12/26/2022] Open
Abstract
Antineutrophil cytoplasmic antibody- (ANCA-) associated vasculitis (AAV) is characterized by small-vessel inflammation in association with autoantibodies. Balance between T follicular helper (Tfh) cells and T follicular regulatory (Tfr) cells is critical for humoral immune responses. Accumulating evidence supports that Tfh and Tfr are involved in autoimmune diseases; however, their roles in AAV are unclear. In this study, we tested the changes of circulatory Tfh and Tfr in patients with AAV. Twenty patients with AAV and twenty healthy controls were enrolled. Sixteen AAV patients had kidney involvement. We found that the AAV patients had increased circulating Tfh cells (CD4+CXCR5+CD25-CD127interm-hi), decreased Tfr cells (CD4+CXCR5+CD25+CD127lo-interm), and elevated Tfh/Tfr ratios compared with healthy controls (P < 0.01). The Tfh percentage and Tfh/Tfr ratio, but not Tfr percentage, were positively correlated to proteinuria levels and BVAS scores in patients with AAV (P < 0.01). In addition, AAV patients had decreased circulating Tfh1 (CCR6-CXCR3+), but increased Tfh2 cells (CCR6-CXCR3-), compared with healthy controls (P < 0.01), indicating a Tfh1-to-Tfh2 shift. Furthermore, remission achieved by immunosuppressive treatment markedly attenuated the increase of total Tfh (P < 0.01) and Tfh2 cells (P < 0.05), promoted the Tfh1 response (P < 0.05), and recovered the balance between Tfh/Tfr cells (P < 0.05) and between Tfh1/Tfh2 cells (P < 0.05) in patients with AAV. Plasma levels of IL-21, a cytokine secreted by Tfh cells, were elevated in AAV patients compared with healthy controls (P < 0.01), which was attenuated by immunosuppressive treatment (P < 0.05). Taken together, our findings indicate that circulatory Tfh/Tfr ratios, Tfh2/Tfh1 shift, and plasma IL-21 levels are associated with AAV and disease activity.
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15
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Schirmer JH, Aries PM, de Groot K, Hellmich B, Holle JU, Kneitz C, Kötter I, Lamprecht P, Müller-Ladner U, Reinhold-Keller E, Specker C, Zänker M, Moosig F. [S1 guidelines Diagnostics and treatment of ANCA-associated vasculitis]. Z Rheumatol 2019; 76:77-104. [PMID: 29204681 DOI: 10.1007/s00393-017-0394-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jan Henrik Schirmer
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
| | - Peer M Aries
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - Kirsten de Groot
- Medizinische Klinik III, Sana Klinikum Offenbach, Offenbach, Deutschland
- KfH Nierenzentrum Offenbach, Offenbach, Deutschland
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Klinik Kirchheim, Kirchheim, Deutschland
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Christian Kneitz
- Klinik für Innere Medizin II, Rheumatologie, klinische Immunologie und Geriatrie, Klinikum Südstadt, Rostock, Deutschland
| | - Ina Kötter
- Abteilung für Rheumatologie, klinische Immunologie und Nephrologie, Asklepios Klinikum Altona, Hamburg, Deutschland
| | - Peter Lamprecht
- Klinik für Rheumatologie und klinische Immunologie, Universität zu Lübeck, Lübeck, Deutschland
| | - Ulf Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Campus Kerckhoff, Justus-Liebig Universität Giessen, Bad Nauheim, Deutschland
| | - Eva Reinhold-Keller
- Klinik für Rheumatologie und klinische Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Christof Specker
- Klinik für Rheumatologie und klinische Immunologie, Universitätsmedizin Essen, St. Josef Krankenhaus Werden, Essen, Deutschland
| | - Michael Zänker
- Abteilung für Innere Medizin, Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Deutschland
- Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
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16
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Sattui SE, Spiera RF. Treatment of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Is There Still a Role for Cyclophosphamide? Rheum Dis Clin North Am 2019; 45:379-398. [PMID: 31277751 DOI: 10.1016/j.rdc.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of systemic necrotizing vasculitides that includes granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis. Treatment of these conditions has improved during the past 2 decades with better understanding of these conditions and availability of newer agents. Cyclophosphamide (CYC) was the first drug demonstrated to afford successful treatment and improvement in AAV. With the emergence of newer agents with more favorable safety profiles, CYC is no longer the cornerstone of management of AAV. This article reviews existing data for treatment and the current role of CYC in the management of AAV.
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Affiliation(s)
- Sebastian E Sattui
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Robert F Spiera
- Division of Rheumatology, Department of Medicine, Weill Cornell Medical College, Scleroderma, Vasculitis & Myositis Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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17
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All‐Cause and Cause‐Specific Mortality in Patients With Granulomatosis With Polyangiitis: A Population‐Based Study. Arthritis Care Res (Hoboken) 2018; 71:155-163. [DOI: 10.1002/acr.23587] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 04/17/2018] [Indexed: 12/11/2022]
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18
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Koh JH, Kemna MJ, Cohen Tervaert JW, Kim WU. Editorial: Can an Increase in Antineutrophil Cytoplasmic Autoantibody Titer Predict Relapses in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis? Arthritis Rheumatol 2018; 68:1571-3. [PMID: 26882278 DOI: 10.1002/art.39639] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/09/2016] [Indexed: 01/18/2023]
Affiliation(s)
- Jung Hee Koh
- The Catholic University of Korea, Seoul, Republic of Korea
| | - Michael Joseph Kemna
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | | | - Wan-Uk Kim
- The Catholic University of Korea, Seoul, Republic of Korea
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19
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Salvadori M, Tsalouchos A. Antineutrophil cytoplasmic antibody associated vasculitides with renal involvement: Open challenges in the remission induction therapy. World J Nephrol 2018; 7:71-83. [PMID: 29736379 PMCID: PMC5937030 DOI: 10.5527/wjn.v7.i3.71] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/12/2018] [Accepted: 04/18/2018] [Indexed: 02/06/2023] Open
Abstract
Renal involvement with rapidly progressive glomerulonephritis is a common manifestation of antineutrophil cytoplasmic antibody (ANCA) associated vasculitides, which is characterized by end-stage renal disease and high mortality rates in untreated and/or late referral patients. The long-term renal survival has improved dramatically since the addition of cyclophosphamide (CYC) and recently of rituximab (RTX) in association with corticosteroids in the remission induction therapeutic regimens. However, renal prognosis remains unfavorable for many patients and the mortality rate is still significantly high. In this review, we analyze the open challenges to be addressed to optimize the induction remission therapy, principally in patients with advanced kidney failure. This concern the first-line therapy (CYC or RTX) based on different parameters (estimated glomerular filtration rate at baseline, new or relapsed disease, ANCA specificity, tissue injury, safety), the role of plasma exchange and the role of new therapies. Indeed, we discuss future perspectives in induction remission therapy by reporting recent advances in new targeted therapies with particular reference to avacopan, an orally administered selective C5a receptor inhibitor.
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Affiliation(s)
- Maurizio Salvadori
- Department of Nephrology and Renal Transplantation, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Department of Nephrology and Dialysis, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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20
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Cornec D, Kabat BF, Mills JR, Cheu M, Hummel AM, Schroeder DR, Cascino MD, Brunetta P, Murray DL, Snyder MR, Fervenza F, Hoffman GS, Kallenberg CGM, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, St Clair EW, Stone JH, Barnidge DR, Specks U. Pharmacokinetics of rituximab and clinical outcomes in patients with anti-neutrophil cytoplasmic antibody associated vasculitis. Rheumatology (Oxford) 2018; 57:639-650. [PMID: 29340623 PMCID: PMC5888934 DOI: 10.1093/rheumatology/kex484] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 11/10/2017] [Indexed: 12/16/2022] Open
Abstract
Objectives To study the determinants of the pharmacokinetics (PK) of rituximab (RTX) in patients with ANCA-associated vasculitis (AAV) and its association with clinical outcomes. Methods This study included data from 89 patients from the RTX in AAV trial who received the full dose of RTX (four weekly infusions of 375 mg/m2). RTX was quantified at weeks 2, 4, 8, 16 and 24, and summarized by computing the trapezoidal area under the curve. We explored potential determinants of the PK-RTX, and analysed its association with clinical outcomes: achievement of remission at 6 months, duration of B-cell depletion and time to relapse in patients who achieved complete remission. Results RTX serum levels were significantly lower in males and in newly diagnosed patients, and negatively correlated with body surface area, baseline B-cell count and degree of disease activity. In multivariate analyses, the main determinants of PK-RTX were sex and new diagnosis. Patients reaching complete remission at month 6 had similar RTX levels compared with patients who did not reach complete remission. Patients with higher RTX levels generally experienced longer B-cell depletion than patients with lower levels, but RTX levels at the different time points and area under the curve were not associated with time to relapse. Conclusion Despite the body-surface-area-based dosing protocol, PK-RTX is highly variable among patients with AAV, its main determinants being sex and newly diagnosed disease. We did not observe any relevant association between PK-RTX and clinical outcomes. The monitoring of serum RTX levels does not seem clinically useful in AAV.
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Affiliation(s)
- Divi Cornec
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Rheumatology Department, Brest University Hospital, and INSERM U1227, Brest, France
| | - Brian F Kabat
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Amber M Hummel
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Melissa R Snyder
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Gary S Hoffman
- Division of Rheumatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Carol A Langford
- Division of Rheumatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Peter A Merkel
- Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Paul A Monach
- Rheumatology, Boston University Medical Center, Boston, MA
| | - Philip Seo
- Rheumatology, Johns Hopkins University, Baltimore, MD
| | | | | | - John H Stone
- Rheumatology, Massachusetts General Hospital, Boston, MA, USA
| | - David R Barnidge
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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21
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the efficacy and safety of rituximab (RTX) as a remission induction and maintenance therapy in ANCA-associated vasculitis (AAV). RECENT FINDINGS A PubMed search was carried out to track down articles published between February 2006 and February 2016. Randomized controlled trials (RCTs) that encompassed patients with AAV were included. The American College of Rheumatology (ACR) and the European League against Rheumatism (EULAR) 2014-2015 online abstracts were also reviewed whether they were RTCs or not. Ten PubMed RCTs were analyzed along with eight ACR and four EULAR abstracts. RTX was not inferior to cyclophosphamide (CYC) for remission induction in AAV; it was superior to CYC in patients with relapsing disease and superior for remission maintenance in comparison with azathioprine (AZA). Rituximab is a therapeutic option to induce and maintain remission in patients with AAV.
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Affiliation(s)
- Romina I Hassan
- Division of Rheumatology, J. M. Ramos Mejia Hospital, 609 General Urquiza Street, Buenos Aires, 1221, Argentina.
| | - Angelo L Gaffo
- Birmingham VA Medical Center, 700 19th St S., Birmingham, AL, 35233, USA.,Division of Rheumatology and Clinical Immunology, University of Alabama at Birmingham, 1825 University Blvd, SHEL 306, Birmingham, AL, 35294-2182, USA
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22
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Cornec D, Cornec-Le Gall E, Specks U. Clinical trials in antineutrophil cytoplasmic antibody-associated vasculitis: what we have learnt so far, and what we still have to learn. Nephrol Dial Transplant 2017; 32:i37-i47. [PMID: 28087591 DOI: 10.1093/ndt/gfw384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
The prognosis of the antineutrophil cytoplasmic antibody associated vasculitides (AAV), microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA) and eosinophilic GPA (EGPA), has been fundamentally improved over the last five decades by the use of glucocorticoids and immunosuppressants, turning them from consistently fatal diseases into chronic conditions. The long-term course is now largely determined by the frequency of disease flares and by accruing damage caused by disease activity and treatment-related comorbidities. This review summarizes the evidence derived from clinical trials performed during the last 30 years and the remaining clinical unmet needs that new studies aim to address. In MPA and GPA, ongoing studies assess (i) different strategies to reduce cumulative glucocorticoid doses currently used for induction and maintenance of remission, (ii) the efficacy of new drugs and (iii) the optimal duration of immunosuppression and the use of biomarkers to individualize therapy. Prospective randomized trials also target disease-associated cardiovascular risk and infections. The first prospective controlled trials specifically designed for EGPA have recently been launched and could lead to new therapeutic options for patients diagnosed with this rare disease. This is an exciting time for researchers in the field of AAV, and for patients as collaborative efforts raise the hope of developing new therapies and more individualized approaches to the management of the diseases, maximizing efficacy while minimizing treatment toxicities.
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Affiliation(s)
- Divi Cornec
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, MN, USA.,European University of Brittany and Brest University Hospital, Brest, France
| | - Emilie Cornec-Le Gall
- European University of Brittany and Brest University Hospital, Brest, France.,Division of Nephrology, Mayo Clinic Rochester, MN, USA
| | - Ulrich Specks
- Thoracic Disease Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, MN, USA
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23
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Shi L. Anti-neutrophil cytoplasmic antibody-associated vasculitis: prevalence, treatment, and outcomes. Rheumatol Int 2017; 37:1779-1788. [DOI: 10.1007/s00296-017-3818-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
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24
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Abstract
Vasculitides comprise several diseases affecting vessels of different sizes, mainly arteries, but also capillaries and veins. Antineutrophil cytoplasm antibody-associated vasculitides (AAVs) belong to the systemic necrotizing small-vessel vasculitis group that comprises granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. Internists often see AAV patients, and although their outcomes are usually good, the disease can be responsible for morbidity and mortality. Herein, after reviewing the literature, we concentrate on selected aspects important for the internist, including classification, diagnostic dilemmas, treatment novelties, and follow-up.
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Affiliation(s)
- Benjamin Chaigne
- Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France.
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Souza AWSD, Calich AL, Mariz HDA, Ochtrop MLG, Bacchiega ABS, Ferreira GA, Rêgo J, Perez MO, Pereira RMR, Bernardo WM, Levy RA. Recommendations of the Brazilian Society of Rheumatology for the induction therapy of ANCA-associated vasculitis. REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57 Suppl 2:484-496. [PMID: 28754431 DOI: 10.1016/j.rbre.2017.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/21/2017] [Indexed: 12/31/2022] Open
Abstract
The purpose of these recommendations is to guide the appropriate induction treatment of antineutrophil cytoplasmic antibody-associated vasculitis (AAV) patients with active disease. The recommendations proposed by the Vasculopathies Committee of the Brazilian Society Rheumatology for induction therapy of AAV, including granulomatosis with polyangiitis, microscopic polyangiitis and renal-limited vasculitis, were based on systematic literature review and expert opinion. Literature review was performed using Medline (PubMed), EMBASE and Cochrane database to retrieve articles until October 2016. PRISMA guidelines were used for the systematic review and articles were assessed according to the Oxford levels of evidence. Sixteen recommendations were made regarding different aspects of induction therapy for AAV. The purpose of these recommendations is to serve as a guide for therapeutic decisions by health care professionals in the management of AAV patients presenting active disease.
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Affiliation(s)
- Alexandre Wagner Silva de Souza
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Disciplina de Reumatologia, São Paulo, SP, Brazil.
| | - Ana Luisa Calich
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Disciplina de Reumatologia, São Paulo, SP, Brazil
| | | | - Manuella Lima Gomes Ochtrop
- Universidade do Estado do Rio de Janeiro (UERJ), Hospital Universitário Pedro Ernesto, Serviço de Reumatologia, Rio de Janeiro, RJ, Brazil
| | - Ana Beatriz Santos Bacchiega
- Universidade do Estado do Rio de Janeiro (UERJ), Hospital Universitário Pedro Ernesto, Serviço de Reumatologia, Rio de Janeiro, RJ, Brazil
| | - Gilda Aparecida Ferreira
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento Aparelho Locomotor, Belo Horizonte, MG, Brazil
| | - Jozelia Rêgo
- Universidade Federal de Goiás (UFG), Faculdade de Medicina, Serviço de Reumatologia, Goiânia, GO, Brazil
| | - Mariana Ortega Perez
- Universidade de São Paulo (USP), Faculdade de Medicina, Disciplina de Reumatologia, São Paulo, SP, Brazil
| | | | | | - Roger Abramino Levy
- Universidade do Estado do Rio de Janeiro (UERJ), Hospital Universitário Pedro Ernesto, Serviço de Reumatologia, Rio de Janeiro, RJ, Brazil
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Miloslavsky EM, Lu N, Unizony S, Choi HK, Merkel PA, Seo P, Spiera R, Langford CA, Hoffman GS, Kallenberg CGM, St Clair EW, Tchao NK, Fervenza F, Monach PA, Specks U, Stone JH. Myeloperoxidase-Antineutrophil Cytoplasmic Antibody (ANCA)-Positive and ANCA-Negative Patients With Granulomatosis With Polyangiitis (Wegener's): Distinct Patient Subsets. Arthritis Rheumatol 2017; 68:2945-2952. [PMID: 27428559 DOI: 10.1002/art.39812] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/07/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the relationship of antineutrophil cytoplasmic antibody (ANCA) type and ANCA-associated vasculitis (AAV) diagnosis with demographic features, disease manifestations, and clinical outcomes. We focused on patients who account for the differences between ANCA type and disease type classifications: anti-myeloperoxidase (MPO)-ANCA-positive and ANCA-negative patients with granulomatosis with polyangiitis (Wegener's) (GPA). METHODS We performed a pooled analysis of the Wegener's Granulomatosis Etanercept Trial and the Rituximab in ANCA-Associated Vasculitis trial comparing patients with MPO-ANCA-positive GPA and patients with ANCA-negative GPA to patients with proteinase 3 (PR3)-ANCA-positive GPA and patients with MPO-ANCA-positive microscopic polyangiitis (MPA). RESULTS Of the 365 patients analyzed, 273 (75%) had PR3-ANCA-positive GPA, 33 (9%) had MPO-ANCA-positive GPA, 15 (4%) had ANCA-negative GPA, and 44 (12%) had MPO-ANCA-positive MPA. MPO-ANCA-positive GPA patients were younger at diagnosis compared to MPO-ANCA-positive MPA patients (53 versus 61 years; P = 0.02). Their disease manifestations and rates of relapse were similar to those of PR3-ANCA-positive GPA patients. Relapse was more frequent in MPO-ANCA-positive GPA patients than in patients with MPO-ANCA-positive MPA at trial entry as well as at 12 and 18 months. ANCA-negative patients with GPA had lower Birmingham Vasculitis Activity Score for Wegener's Granulomatosis scores at trial entry than PR3-ANCA-positive patients with GPA (4.5 versus 7.7; P < 0.01), primarily because of a lower prevalence of renal involvement. CONCLUSION We were unable to demonstrate important clinical differences between MPO-ANCA-positive and PR3-ANCA-positive patients with GPA. The risk of relapse was associated more closely with disease type than with ANCA type in this patient cohort. These findings deserve consideration in the assessment of relapse risk in patients with AAV.
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Affiliation(s)
| | - Na Lu
- Massachusetts General Hospital, Boston
| | | | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | | | - Nadia K Tchao
- Immune Tolerance Network, South San Francisco, California
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Fussner LA, Hummel AM, Schroeder DR, Silva F, Cartin-Ceba R, Snyder MR, Hoffman GS, Kallenberg CGM, Langford CA, Merkel PA, Monach PA, Seo P, Spiera RF, William St Clair E, Tchao NK, Stone JH, Specks U. Factors Determining the Clinical Utility of Serial Measurements of Antineutrophil Cytoplasmic Antibodies Targeting Proteinase 3. Arthritis Rheumatol 2017; 68:1700-10. [PMID: 26882078 DOI: 10.1002/art.39637] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Relapse following remission is common in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), particularly with ANCAs directed at proteinase 3 (PR3). This study was undertaken to evaluate the association of an increase in PR3-ANCA level with subsequent relapse. METHODS Data from the Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis (RAVE) trial were used. Starting from the time of achieving complete remission, serial measurements by direct and capture enzyme-linked immunosorbent assays (ELISAs) were analyzed in 93 patients with PR3-ANCA, using Cox proportional hazards regression. RESULTS An increase in PR3-ANCA level was identified in 58 of 93 subjects (62.4%) by direct ELISA and in 59 of 93 (63.4%) by capture ELISA. Relapses occurred in 55 of 93 subjects (59.1%), with 25 and 21 occurring within 1 year after an increase by direct ELISA and capture ELISA, respectively. An increase by direct ELISA was associated with subsequent severe relapses (hazard ratio [HR] 4.57; P < 0.001), particularly in patients presenting with renal involvement (HR 7.94; P < 0.001) and alveolar hemorrhage (HR 24.19; P < 0.001). Both assays identified increased risk for severe relapse in the rituximab group (HR 5.80; P = 0.002 for direct ELISA and HR 4.54; P = 0.007 for capture ELISA) but not the cyclophosphamide/azathioprine group (P = 0.103 and P = 0.197, respectively). CONCLUSION The association of an increase in PR3-ANCA level with the risk of subsequent relapse is partially affected by the PR3-ANCA detection methodology, disease phenotype, and remission induction treatment. An increase in PR3-ANCA level during complete remission conveys an increased risk of relapse, particularly severe relapse, among patients with renal involvement or alveolar hemorrhage and those treated with rituximab. Serial measurements of PR3-ANCA may be informative in this subset of patients, but the risk of relapse must be weighed carefully against the risks associated with therapy.
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Affiliation(s)
- Lynn A Fussner
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | - Amber M Hummel
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | - Darrell R Schroeder
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | | | - Rodrigo Cartin-Ceba
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | - Melissa R Snyder
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
| | | | | | | | | | - Paul A Monach
- Boston University, Boston University Medical Center, and VA Boston Healthcare System, Boston, Massachusetts
| | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - John H Stone
- Massachusetts General Hospital, Boston, Massachusetts
| | - Ulrich Specks
- Mayo Clinic and Mayo Foundation for Medical Education and Research, Rochester, Minnesota
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28
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Wang H, Zhang C, Tong Z, Bu X. Elevated serum levels of immunoglobulin A correlate with the possibility of readmission in patients with microscopic polyangiitis. J Thorac Dis 2017; 9:1201-1208. [PMID: 28616269 DOI: 10.21037/jtd.2017.03.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The evidence for the short-term prognosis of patients with microscopic polyangiitis (MPA) is weak, and the objective of this study was to analyze the clinical features of the disease and evaluate the risk factors for readmission in patients with MPA. METHODS Fifty-seven patients with MPA were recruited into this study. The clinical data of these MPA patients were collected. Clinical manifestations, laboratory results, and imaging results were analyzed. Patients who were readmitted to our hospital within 6 months after their first diagnosis and treatment of MPA were defined as the readmission group; the remaining patients were defined as the control group. RESULTS Respiratory symptoms, including cough, dyspnea (87.72%), and hemoptysis (3.51%), seemed to be the initial symptoms in many patients with MPA. Systemic symptoms included fever (71.93%), hearing loss (12.28%), vision loss (3.51%), and joint involvement (5.27%). The D-dimer levels of 43 patients (75.44%) were >500 ng/dL, and only three of these patients had venous thrombosis. Age and immunoglobulin A (IgA) were the risk factors for readmission in patients with MPA, with odds ratios (ORs) of 1.162 [95% confidence interval (CI): 1.025-1.317, P=0.019] and 1.010 (95% CI: 1.001-1.018, P=0.028). The days of hospitalization and the a2-globulin level were protective factors with ORs of 0.849 (95% CI: 0.725-0.993 P=0.041) and 0.789 (95% CI: 0.64-0.971, P=0.025), respectively. IgA levels were positively correlated with the number of hospitalizations, with a correlation coefficient of 0.428 (P=0.002). Receiver operating characteristic curve analysis showed that the possibility of readmission increases when the serum levels of IgA were >217.5 mg/dL. CONCLUSION The level of serum IgA is a risk factor for the readmission of patients with MPA, and correlated with the number of hospitalizations in these patients.
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Affiliation(s)
- Huijuan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing 100020, China
| | - Chao Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing 100020, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing 100020, China
| | - Xiaoning Bu
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing 100020, China
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29
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Martinez AR, Faber I, Nucci A, Appenzeller S, França MC. Autoimmune neuropathies associated to rheumatic diseases. Autoimmun Rev 2017; 16:335-342. [DOI: 10.1016/j.autrev.2017.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
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Abstract
Fellows are expected to educate trainees, peers, and patients, during and long after fellowship. However, there has been relatively little emphasis on the acquisition of teaching skills in fellowship programs. Challenges to teaching by fellows during subspecialty training include demanding clinical duties, their limited knowledge base in the field, brief contact time with learners during consultative roles, and, for new fellows, personal unfamiliarity with the learners and hospital culture. Fellows' teaching skills can be improved by formal curricula addressing teaching, and by direct observation and feedback of teaching akin to what is provided for learning clinical care. Further expansion of fellow-as-teacher programs will allow in-depth training for fellows seeking careers as medical educators. Even without such dedicated programs, emphasis on honing teaching skills during fellowship will telegraph the importance of teaching and help evolve divisional culture. Such efforts can have a positive impact on patients and learners, and enhance the teaching skills of future faculty.
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31
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Souza AWSD, Calich AL, Mariz HDA, Ochtrop MLG, Bacchiega ABS, Ferreira GA, Rêgo J, Perez MO, Pereira RMR, Bernardo WM, Levy RA. Recomendações da Sociedade Brasileira de Reumatologia para a terapia de indução para vasculite associada a ANCA. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Zielińska KA, Van Moortel L, Opdenakker G, De Bosscher K, Van den Steen PE. Endothelial Response to Glucocorticoids in Inflammatory Diseases. Front Immunol 2016; 7:592. [PMID: 28018358 PMCID: PMC5155119 DOI: 10.3389/fimmu.2016.00592] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 11/29/2016] [Indexed: 12/16/2022] Open
Abstract
The endothelium plays a crucial role in inflammation. A balanced control of inflammation requires the action of glucocorticoids (GCs), steroidal hormones with potent cell-specific anti-inflammatory properties. Besides the classic anti-inflammatory effects of GCs on leukocytes, recent studies confirm that endothelial cells also represent an important target for GCs. GCs regulate different aspects of endothelial physiology including expression of adhesion molecules, production of pro-inflammatory cytokines and chemokines, and maintenance of endothelial barrier integrity. However, the regulation of endothelial GC sensitivity remains incompletely understood. In this review, we specifically examine the endothelial response to GCs in various inflammatory diseases ranging from multiple sclerosis, stroke, sepsis, and vasculitis to atherosclerosis. Shedding more light on the cross talk between GCs and endothelium will help to improve existing therapeutic strategies and develop new therapies better tailored to the needs of patients.
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Affiliation(s)
- Karolina A. Zielińska
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Laura Van Moortel
- Receptor Research Laboratories, Nuclear Receptor Lab, VIB-UGent, VIB Medical Biotechnology Center, Ghent, Belgium
| | - Ghislain Opdenakker
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Karolien De Bosscher
- Receptor Research Laboratories, Nuclear Receptor Lab, VIB-UGent, VIB Medical Biotechnology Center, Ghent, Belgium
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33
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Affiliation(s)
- David Saadoun
- a Département Hospitalo Universitaire I2B immunopathologie, inflammation et biothérapie, Centre de référence des maladies Autoimmunes et Systémiques rares, Service de Médecine Interne et d'Immunologie Clinique, AP-HP, Hôpital Pitié-Salpêtrière , Université Pierre et Marie Curie-Paris 6, UMR 7211 (CNRS/UPMC) INSERM U959 , Paris , France
| | - Patrice Cacoub
- a Département Hospitalo Universitaire I2B immunopathologie, inflammation et biothérapie, Centre de référence des maladies Autoimmunes et Systémiques rares, Service de Médecine Interne et d'Immunologie Clinique, AP-HP, Hôpital Pitié-Salpêtrière , Université Pierre et Marie Curie-Paris 6, UMR 7211 (CNRS/UPMC) INSERM U959 , Paris , France
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Yates M, Watts RA, Bajema IM, Cid MC, Crestani B, Hauser T, Hellmich B, Holle JU, Laudien M, Little MA, Luqmani RA, Mahr A, Merkel PA, Mills J, Mooney J, Segelmark M, Tesar V, Westman K, Vaglio A, Yalçındağ N, Jayne DR, Mukhtyar C. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis 2016; 75:1583-94. [PMID: 27338776 DOI: 10.1136/annrheumdis-2016-209133] [Citation(s) in RCA: 744] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/27/2016] [Indexed: 12/13/2022]
Abstract
In this article, the 2009 European League Against Rheumatism (EULAR) recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have been updated. The 2009 recommendations were on the management of primary small and medium vessel vasculitis. The 2015 update has been developed by an international task force representing EULAR, the European Renal Association and the European Vasculitis Society (EUVAS). The recommendations are based upon evidence from systematic literature reviews, as well as expert opinion where appropriate. The evidence presented was discussed and summarised by the experts in the course of a consensus-finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) determined. In addition to the voting by the task force members, the relevance of the recommendations was assessed by an online voting survey among members of EUVAS. Fifteen recommendations were developed, covering general aspects, such as attaining remission and the need for shared decision making between clinicians and patients. More specific items relate to starting immunosuppressive therapy in combination with glucocorticoids to induce remission, followed by a period of remission maintenance; for remission induction in life-threatening or organ-threatening AAV, cyclophosphamide and rituximab are considered to have similar efficacy; plasma exchange which is recommended, where licensed, in the setting of rapidly progressive renal failure or severe diffuse pulmonary haemorrhage. These recommendations are intended for use by healthcare professionals, doctors in specialist training, medical students, pharmaceutical industries and drug regulatory organisations.
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Affiliation(s)
- M Yates
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK Norwich Medical School, University of East Anglia, Norwich, UK
| | - R A Watts
- Norwich Medical School, University of East Anglia, Norwich, UK Department of Rheumatology, Ipswich Hospital NHS Trust, Ipswich, Suffolk, UK
| | - I M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - B Crestani
- Assistance Publique-Hôpitaux de Paris, Department of Pulmonology, Bichat-Claude Bernard University Hospital, Paris, France
| | - T Hauser
- Immunologie-Zentrum Zürich, Zürich, Switzerland
| | - B Hellmich
- Vaskulits-Zentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Kreiskliniken Esslingen, Kirchheim-Teck, Germany
| | - J U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - M Laudien
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Kiel, Kiel, Germany
| | - M A Little
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - R A Luqmani
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - A Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, Université Paris 7 René Diderot, Paris, France
| | - P A Merkel
- Division of Rheumatology and the Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Mills
- Vasculitis UK, West Bank House, Winster, Matlock, UK
| | - J Mooney
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - M Segelmark
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden Department of Nephrology, Linköping University, Linköping, Sweden
| | - V Tesar
- Department of Nephrology, 1st School of Medicine, Charles University, Prague, Czech Republic
| | - K Westman
- Department of Nephrology, Lund University, Skåne University Hospital, Lund and Malmö, Sweden
| | - A Vaglio
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - N Yalçındağ
- Department of Ophthalmology, School of Medicine, Ankara University, Ankara, Turkey
| | - D R Jayne
- Lupus and Vasculitis Unit, Addenbrooke's Hospital, Cambridge, UK
| | - C Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
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35
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Keller SF, Miloslavsky EM. Corticosteroids in Antineutrophil Cytoplasmic Antibody–Associated Vasculitis. Rheum Dis Clin North Am 2016; 42:91-101, viii. [DOI: 10.1016/j.rdc.2015.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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