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Schirmer JH, Sanchez-Alamo B, Hellmich B, Jayne D, Monti S, Luqmani RA, Tomasson G. Systematic literature review informing the 2022 update of the EULAR recommendations for the management of ANCA-associated vasculitis (AAV): part 1-treatment of granulomatosis with polyangiitis and microscopic polyangiitis. RMD Open 2023; 9:e003082. [PMID: 37479496 PMCID: PMC10364171 DOI: 10.1136/rmdopen-2023-003082] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/16/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVE To summarise and update evidence to inform the 2022 update of the EULAR recommendations for the management of antineutrophil cytoplasm antibody-associated vasculitis (AAV). METHODS A systematic literature review (SLR) was performed to identify current evidence regarding treatment of AAV. PubMed, EMBASE and the Cochrane library were searched from 1 February 2015 to 25 February 2022. The evidence presented here is focused on the treatment of granulomatosis with polyangiitis and microscopic polyangiitis. RESULTS 3517 articles were screened and 175 assessed by full-text review. Ninety articles were included in the final evidence synthesis. Cyclophosphamide and rituximab (RTX) show similar efficacy for remission induction (level of evidence (LoE) 1a) but RTX is more effective in relapsing disease (LoE 1b). Glucocorticoid (GC) protocols with faster tapering result in similar remission rates but lower rates of serious infections (LoE 1b). Avacopan can be used to rapidly taper and replace GC (LoE 1b). Data on plasma exchange are inconsistent depending on the analysed trial populations but meta-analyses based on randomised controlled trials demonstrate a reduction of the risk of end-stage kidney disease at 1 year but not during long-term follow-up (LoE 1a). Use of RTX for maintenance of remission is associated with lower relapse rates compared with azathioprine (AZA, LoE 1b). Prolonged maintenance treatment results in lower relapse rates for both, AZA (LoE 1b) and RTX (LoE 1b). CONCLUSION This SLR provides current evidence to inform the 2022 update of the EULAR recommendations for the management of AAV.
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Affiliation(s)
- Jan Henrik Schirmer
- Clinic for Internal Medicine I, Rheumatology and Clinical Immunology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Beatriz Sanchez-Alamo
- Nephrology, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
- Nephrology, Skåne University Hospital, Lund, Sweden
| | - Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken Kirchheim/Teck, University Tübingen, Kirchheim-Teck, Germany
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, University of Pavia; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raashid Ahmed Luqmani
- Oxford NIHR Biomedical Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gunnar Tomasson
- Faculty of Medicine, University of Iceland, Landspitali University Hospital, Reykjavik, Iceland
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Bhat R, Tonutti A, Timilsina S, Selmi C, Gershwin ME. Perspectives on Mycophenolate Mofetil in the Management of Autoimmunity. Clin Rev Allergy Immunol 2023:10.1007/s12016-023-08963-3. [PMID: 37338709 DOI: 10.1007/s12016-023-08963-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
Before becoming a cornerstone in the treatment of numerous immune-mediated diseases, mycophenolate mofetil (MMF) was first introduced as an immunosuppressive agent in transplant immunology and later received the attention of rheumatologists and clinicians involved in the management of autoimmune diseases. MMF is now a widespread immunosuppressive drug for the treatment of several conditions, including lupus nephritis, interstitial lung disease associated with systemic sclerosis, and anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis while being efficacious also as rescue therapy in various orphan diseases, including dermatomyositis and IgA-associated nephropathy. Similarly, case reports or series support a possible use of MMF in other rare autoimmune diseases. Beyond modulating lymphocyte activation, MMF acts on other immune and non-immune cells and these effects may explain the therapeutic profile of this medication. The effects of MMF are broadly characterized by the impact on the immune system and the antiproliferative and antifibrotic changes induced. In this latter case, mechanistic data on fibroblasts may in the future allow to reevaluate the use of MMF in selected patients with inflammatory arthritis or systemic sclerosis. Attention must be paid towards the possible occurrence of adverse events, such as gastrointestinal complaints and teratogenicity, while the risk of infections and cancer related to MMF needs to be further investigated.
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Affiliation(s)
- Rithika Bhat
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Suraj Timilsina
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA.
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Berti A, Alsawas M, Jawaid T, Prokop LJ, Lee JM, Jeong GH, Quintana LF, Moiseev S, Vaglio A, Tesar V, Geetha D, Shin JI, Kronbichler A. Induction and maintenance of remission with mycophenolate mofetil in ANCA-associated vasculitis: A systematic review and meta-analysis. Nephrol Dial Transplant 2021; 37:2190-2200. [PMID: 34910216 DOI: 10.1093/ndt/gfab357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Uncertainties exist about the use of mycophenolate mofetil (MMF) in anti-neutrophil cytoplasmatic antibody (ANCA)-associated vasculitis (AAV), particularly for remission maintenance. METHODS Systematic review and meta-analysis of phase II and III trials assessing the use of MMF in AAV (granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA)). A comprehensive search of several databases (Medline, EMBASE, Cochrane, Web of Science, Scopus) from inception to May 5th, 2020 has been conducted. Trial data were extracted to estimate odds ratios (ORs) and estimates (ES) for MMF efficacy (remission-induction and maintenance). Severe adverse effects (SAEs) were collected. RESULTS From 565 articles captured, 10 met the predefined criteria, five phase II and five III trials, 4 assessed remission-induction, 3 remission-maintenance, 3 both. The pooled OR for remission-induction at 6 months was 1.06 (95% CI: [0.74, 1.52]), with no significant difference by subgroup meta-analysis of trials stratified by different study-level features (i.e. kidney disease, MPA, myeloperoxidase-ANCA-positivity, newly diagnosed disease) (p > 0.05).The overall ES for remission-maintenance at the end of follow-up ranged between 51%-91% (I2 = 74.8%). Subgroup meta-analysis identified kidney involvement as a possible source of heterogeneity, yielding a significantly higher rate of sustained remission in trials enrolling only patients with kidney involvement (92% [76%-100%]) versus those enrolling patients with and without kidney involvement (56% [45%-66%]). Results were similar in multiple sensitivity analyses.During follow-up, the frequency of SAEs in MMF-based treatment arms was 31.8%. CONCLUSIONS In AAV, MMF use significantly associated with higher sustained remission rates in trials enrolling only patients with kidney involvement. These findings might influence clinical practice.
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Affiliation(s)
- Alvise Berti
- Santa Chiara Regional Hospital and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Rheumatology, Trento, Italy
| | - Mouaz Alsawas
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.,Department of Pathology, University of Iowa, IA City, IA, USA
| | - Tabinda Jawaid
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
| | | | - Jiwon M Lee
- Korea Disease Control and Prevention Agency, Division of Rare Disease Management, Republic of Korea
| | - Gwang Hun Jeong
- College of Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Luis F Quintana
- Reference Center in Complex Glomerular Disease of the National Health System (CSUR), Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain. Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - August Vaglio
- Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, and Nephrology Unit, Meyer Children's Hospital, Firenze, Italy
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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Philobos M, Perkins A, Karabayas M, Dospinescu P, Fluck N, Kidder D, Chapman FA, Dhaun N, Basu N. A real-world assessment of mycophenolate mofetil for remission induction in eosinophilic granulomatosis with polyangiitis. Rheumatol Int 2021; 41:1811-1814. [PMID: 34350491 PMCID: PMC8390413 DOI: 10.1007/s00296-021-04961-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/27/2021] [Indexed: 10/30/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a form of ANCA-associated vasculitis (AAV). Clinical trials demonstrating the efficacy of mycophenolate mofetil (MMF) for remission induction in AAV excluded patients with EGPA. Despite this, MMF is commonly used in these patients. The objective of this study was to evaluate, for the first time, the effectiveness and tolerance of MMF in EGPA remission induction. A retrospective, two-center, real-world study was conducted in patients with EGPA who received MMF in addition to prednisolone for newly diagnosed or relapsing disease between 2009 and 2019. Baseline, 3-, 6- and 12-month outcome data were extracted from electronic health records. The primary outcome was disease remission, defined as a Birmingham Vasculitis Activity Score of 0 at 6 months. Secondary outcomes included disease relapse, median prednisolone dose at 12 months and drug tolerance. In total, 15 patients (73% male, median age 57) with EGPA (11 newly diagnosed/4 relapsing) were identified. At 6 months, 67% had achieved disease remission. At 12 months, this was maintained (66.7%) and 4 patients had relapsed. All but one patient remained on MMF at study completion and all patients tolerated MMF. Our real-world data suggest that MMF is an effective and well-tolerated agent for achieving disease remission in EGPA. A future randomized controlled trial of MMF in this neglected orphan disease is now warranted.
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Affiliation(s)
| | - Amy Perkins
- Rheumatology Unit, NHS Grampian, Aberdeen, UK
| | | | | | - Nick Fluck
- Renal Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Dana Kidder
- Renal Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Fiona A Chapman
- Renal Unit, Edinburgh Royal Infirmary, NHS Lothian, Edinburgh, UK
| | - Neeraj Dhaun
- Renal Unit, Edinburgh Royal Infirmary, NHS Lothian, Edinburgh, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
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Xiong A, Xiong C, Yang G, Shuai Y, Liu D, He L, Guo Z, Zhang L, Liu Y, Yang Y, Cui B, Shuai S. The Role of Mycophenolate Mofetil for the Induction of Remission in ANCA-Associated Vasculitis: A Meta-Analysis. Front Med (Lausanne) 2021; 8:609924. [PMID: 33732714 PMCID: PMC7956966 DOI: 10.3389/fmed.2021.609924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/10/2021] [Indexed: 02/05/2023] Open
Abstract
Objectives: The successful introduction of mycophenolate mofetil (MMF) as a treatment for renal allograft reduced the incidence of acute rejection. The inspiring effects obtained by the MMF have led to an evaluation of its therapeutic potency on ANCA-associated vasculitis (AAV). However, there is little evidence of the MMF's efficacy on the AAV. The meta-analysis is carried out to evaluate the efficacy of MMF as a remission induction therapy in AAV. Methods: Up to June 30th, 2020, PubMed, Cochrane Library, and Embase have been searched comprehensively. According to heterogeneity, the pooled remission rates are synthesized by either fixed-effect or random-effect models. Results: The eight included studies comprising 230 patients who were treated with MMF as induction therapy are included in our analysis. The pooled overall remission rate is 74% (95% CI: 0.68–0.80). The remission rate, the infection rate and the rate of leukopenia of four randomized controlled trials aimed at comparing the effects of MMF with cyclophosphamide (CYC) during induction therapy for AAV have no statistical significance (P > 0.05). Conclusion: MMF may be an alternative to CYC for remission induction therapy in AAV with MPO-ANCA, mild to moderate renal involvement and non-life-threatening state. Whether to observe the effect of MMF in AAV or to compare the difference between MMF and CYC in the future studies, risk stratification and subgrouping of AAV patients should be first carried out to correctly identify the AAV subgroup suitable for MMF.
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Chen Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Guancui Yang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Yu Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Deng Liu
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Linqian He
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Zepeng Guo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Liangwen Zhang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Yang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Beibei Cui
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
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Avello A, Fernandez-Prado R, Santos-Sanchez-Rey B, Rojas-Rivera J, Ortiz A. Slo-Mo anti-neutrophil cytoplasmic antibody-associated renal vasculitis. Clin Kidney J 2021; 14:18-22. [PMID: 33564403 PMCID: PMC7857803 DOI: 10.1093/ckj/sfaa181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/14/2022] Open
Abstract
Nephrologists are familiar with severe cases of anti-neutrophil cytoplasmic antibodies-associated vasculitis (AAV) presenting as rapidly progressive glomerulonephritis. However, less is known about AAV with slowly progressive renal involvement. While its existence is acknowledged in textbooks, much remains unknown regarding its relative frequency versus more aggressive cases as well as about the optimal therapeutic approach and response to therapy. Moreover, this uncommon presentation may be underdiagnosed, given the scarce familiarity of physicians. In this issue of Clinical Kidney Journal, Trivioli et al. report the largest series to date and first systematic assessment of patients with AAV and slowly progressive renal involvement, defined as a reduction in estimated glomerular filtration rate (eGFR) of 25-50% in the 6 months prior to diagnosis after excluding secondary causes. Key findings are that slowly progressive AAV may be less common than previously thought, although it still represents the second most common presentation of renal AAV, it usually has a microscopic polyangiitis, anti-myeloperoxidase, mainly renal phenotype in elderly individuals, diagnosis may be late (over one-third of patients had end-stage kidney disease at diagnosis), clearly identifying an unmet need for physician awareness about this presentation, but those not needing renal replacement therapy at diagnosis still responded to immunosuppression.
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Affiliation(s)
- Alejandro Avello
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Raul Fernandez-Prado
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Begoña Santos-Sanchez-Rey
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Jorge Rojas-Rivera
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Alberto Ortiz
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
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Onuora S. MMF comparable to cyclophosphamide in AAV. Nat Rev Rheumatol 2020; 16:350. [DOI: 10.1038/s41584-020-0440-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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