Journal Article

Randomised controlled trial of prolonged treatment in the remission phase of ANCA-associated vasculitis

Pagnoux, Christian, Tervaert, Jan Willem Cohen, Karras, Alexandre, Haubitz, Marion, Groot, Kirsten de, Jayne, David, Segelmark, Mårten, Puechal, Xavier, Guillevin, Loic

2017

Overview

ObjectivesA prospective randomised trial to compare two different durations of maintenance immunosuppressive therapy for the prevention of relapse in anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV).MethodsPatients with AAV were recruited 18–24 months after diagnosis if they were in stable remission after cyclophosphamide/prednisolone-based induction followed by azathioprine/prednisolone maintenance therapy. They were randomised (1:1) to receive continued azathioprine/prednisolone to 48 months from diagnosis (continuation group) or to withdraw azathioprine/prednisolone by 24 months (withdrawal group). The primary endpoint was the relapse risk, from randomisation to 48 months from diagnosis.ResultsOne hundred and seventeen patients were randomised and 110 remained to the trial end. At entry, median serum creatinine was 116 μmol/L (range 58–372), 53% were ANCA positive. The percentage of patients presenting with relapse was higher in the withdrawal than in the continuation treatment group (63% vs 22%, p<0.0001, OR 5.96, 95% CI 2.58 to 13.77). ANCA positivity at randomisation was associated with relapse risk (51% vs 29%, p=0.017, OR 2.57, 95% CI 1.16 to 5.68). Renal function, ANCA specificity, vasculitis type and age were not predictive of relapse. Severe adverse events were more frequent in the continuation than withdrawal groups (nine vs three events), but the continuation group had better renal outcome (0 vs 4 cases of end-stage renal disease), with no difference in patient survival.ConclusionsProlonged remission maintenance therapy with azathioprine/prednisolone, beyond 24 months after diagnosis reduces relapse risk out to 48 months and improves renal survival in AAV.Trial registration numberISRCTN13739474

• Publisher: BMJ Publishing Group Ltd and European League Against Rheumatism,Elsevier Limited
• Subject: Adult / Aged / ANCA / Anti-Inflammatory Agents - administration & dosage / Anti-Inflammatory Agents - adverse effects / Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis - blood / Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis - complications / Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis - drug therapy / Antibodies / Antibodies, Antineutrophil Cytoplasmic - blood / Antineutrophil cytoplasmic antibodies / Arthritis / Azathioprine / Azathioprine - administration & dosage / Azathioprine - adverse effects / Clinical and epidemiological research / Creatinine / Creatinine - blood / Cyclophosphamide / Cyclophosphamide - therapeutic use / Drug dosages / End-stage renal disease / Female / Glomerular Filtration Rate / Humans / Immunosuppressive agents / Immunosuppressive Agents - administration & dosage / Immunosuppressive Agents - adverse effects / Kidney diseases / Kidney Failure, Chronic - blood / Kidney Failure, Chronic - etiology / Kidney transplantation / Maintenance Chemotherapy - adverse effects / Maintenance Chemotherapy - methods / maintenance therapy / Male / Medical prognosis / Middle Aged / Neutrophils / Prednisolone / Prednisolone - administration & dosage / Prednisolone - adverse effects / Prospective Studies / relapse / Remission / Remission Induction / Renal function / Rheumatology / Secondary Prevention - methods / Survival / Survival Rate / Time Factors / Vasculitis