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Treatments for severe ANCA-associated vasculitis show equal efficacy
Major finding: At 18 months, complete remission was maintained in 39% of patients who had received rituximab and 33% of those who had received...
SAN DIEGO – Retreatment of granulomatosis with polyangiitis or microscopic polyangiitis with rituximab may be safe and effective in reinducing remission, a prospective trial has shown.
"The vast majority of patients with ANCA [antineutrophil cytoplasmic antibody]–associated vasculitis are able to achieve disease remission initially," Dr. Eli Miloslavsky said at the annual meeting of the American College of Rheumatology. "However, there’s a high rate of flare, as frequent as 55% over the first 3 years. Therefore, it’s critical to determine the best remission agent in relapsing disease."
Dr. Eli Miloslavsky
Dr. Miloslavsky presented data from 17 patients in the RAVE (Rituximab in ANCA–Associated Vasculitis) trial who received two courses of rituximab (RTX) and were followed for an average of 301 days. Patients with a severe flare were eligible to receive an open-label course of RTX between 6 and 18 months (375 mg/m2 once a week for 4 weeks). Severe flare was defined as having a Birmingham Vasculitis Activity Score for Wegener’s Granulomatosis (BVAS/WG) of greater than 3 or one major BVAS/WG item. Outcomes were complete remission (no disease activity and being off of steroids), complete response (no disease activity and taking 10 g of prednisone or less), remission (no disease activity regardless of the prednisone dose), limited flare (BVAS/WG of 3 or less), and severe flare (BVAS/WG of greater than 3 or one major disease activity item). At baseline, 82% of patients who received two courses of rituximab were proteinase 3 positive and 88% had granulomatosis with polyangiitis as the clinical diagnosis.
Of the 17 patients, 11 (65%) had relapsing disease at study entry. After receiving a second course of RTX, 15 patients (88%) achieved remission in an average of 2 months, 12 (71%) had at least a complete response in an average of 5 months, and 8 (47%) reached complete remission in an average of 6 months, reported Dr. Miloslavsky of the department of rheumatology at Massachusetts General Hospital, Boston.
At the 12-month time point, 13 patients (76%) had achieved complete responses and 8 (47%) had reached complete remission.
Four flares occurred during the study. "They were all limited and the time to flare was approximately 8 months after receiving RTX," he said.
Three severe adverse events occurred, including one death (a patient with diffuse alveolar hemorrhage who did not improve and died 7 weeks after the initial flare), one case of metastatic colon cancer, and one case of severe sinusitis.
Dr. Miloslavsky acknowledged certain limitations of the study, including the small sample size, the lack of a comparison group, the lack of long-term follow-up, and the limited generalizability to myeloperoxidase-ANCA–positive patients.
The trial was funded by the Immune Tolerance Network, which is supported by the National Institute of Allergy and Infectious Diseases. Partial funding was also derived from Genentech and Biogen Idec.