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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: 102] [Impact Index Per Article: 102.0] [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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Pusztai A, Hamar A, Horváth Á, Gulyás K, Végh E, Bodnár N, Kerekes G, Czókolyová M, Szamosi S, Bodoki L, Hodosi K, Domján A, Nagy G, Szöllősi I, Lopez LR, Matsuura E, Prohászka Z, Szántó S, Nagy Z, Shoenfeld Y, Szekanecz Z, Szűcs G. Soluble Vascular Biomarkers in Rheumatoid Arthritis and Ankylosing Spondylitis: Effects of 1-year Antitumor Necrosis Factor-α Therapy. J Rheumatol 2020; 48:821-828. [PMID: 33323530 DOI: 10.3899/jrheum.200916] [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] [Accepted: 11/27/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) have been associated with cardiovascular disease. The treatment of arthritis by tumor necrosis factor-α (TNF-α) inhibitors may decrease the serum concentrations of vascular biomarkers. We determined circulating levels of oxidized low-density lipoprotein (oxLDL)/β2 glycoprotein I (β2-GPI) complexes, antibodies to 60 kDa heat shock protein (anti-Hsp60), soluble urokinase plasminogen activator receptor (suPAR), and B-type natriuretic peptide (BNP) fragment in sera of RA and AS patients undergoing anti-TNF treatment. METHODS Fifty-three patients with RA/AS were treated with etanercept or certolizumab pegol for 1 year. Circulating oxLDL/β2-GPI complex (AtherOx), anti-Hsp60 IgG, and BNP8-29 fragment levels were assessed by ELISA. suPAR levels were determined by suPARnostic Quick Triage test. Flow-mediated vasodilation (FMD), carotid intima-media thickness (CIMT), and arterial pulse wave velocity (PWV) were determined by ultrasound. RESULTS One-year anti-TNF treatment significantly decreased oxLDL/β2-GPI levels, as well as suPAR levels in patients with critically high suPAR levels at baseline. In RA, BNP levels were higher in seropositive vs seronegative patients. Serum levels of these vascular biomarkers variably correlated with lipids, anticitrullinated protein antibodies, rheumatoid factor, and C-reactive protein. CIMT positively correlated with BNP, and PWV with suPAR and anti-Hsp60, whereas FMD inversely associated with anti-Hsp60. In repeated measures ANOVA analysis, disease activity supported the effects of anti-TNF treatment on 12-month changes in oxLDL/β2-GPI. CIMT supported the effects of therapy on changes in anti-Hsp60 and suPAR. CONCLUSION These biomarkers may be involved in the pathogenesis of atherosclerosis underlying RA/AS. TNF inhibition variably affects the serum levels of oxLDL/β2-GPI, suPAR, and BNP.
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Affiliation(s)
- Anita Pusztai
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Attila Hamar
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ágnes Horváth
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Gulyás
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Edit Végh
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nóra Bodnár
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - György Kerekes
- G. Kerekes, MD, PhD, Intensive Care Unit, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Monika Czókolyová
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Szamosi
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Levente Bodoki
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Hodosi
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Andrea Domján
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gábor Nagy
- G. Nagy, MD, PhD, I. Szöllősi, Department of Laboratory Medicine, University of Debrecen, Debrecen, Hungary
| | - Ibolya Szöllősi
- G. Nagy, MD, PhD, I. Szöllősi, Department of Laboratory Medicine, University of Debrecen, Debrecen, Hungary
| | - Luis R Lopez
- L.R. Lopez, MD, PhD, Corgenix Inc., Broomfield, Colorado, USA
| | - Eiji Matsuura
- E. Matsuura, MD, PhD, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Zoltán Prohászka
- Z. Prohászka, MD, PhD, Third Department of Internal Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Sándor Szántó
- S. Szántó, MD, PhD, Division of Rheumatology, Department of Medicine, and Department of Sports Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Nagy
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Yehuda Shoenfeld
- Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Zoltán Szekanecz
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary;
| | - Gabriella Szűcs
- A. Pusztai, A. Hamar, MD, Á. Horváth, MD, K. Gulyás, MD, E. Végh, MD, N. Bodnár, MD, PhD, M. Czókolyová, S. Szamosi, MD, PhD, L. Bodoki, MD, PhD, K. Hodosi, A. Domján, Z. Nagy, MD, PhD, Z. Szekanecz, MD, PhD, G. Szűcs, MD, PhD, Division of Rheumatology, Department of Medicine, University of Debrecen, Debrecen, Hungary
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