On June 23, 2016, The Annals of the Rheumatic Diseases, released the journal article: EULAR/ERA-EDTA recommendations on the management of ANCA-associated vasculitis.
John Mills Chairman of Vasculitis UK is a member of the panel who took part in the recommendation process. To read the full article please follow this link.
You can join Dr. Richard A. Watts, Consultant Rheumatologist, Nuffield Health Ipswich Hospital, United Kingdom, as he discusses recently released recommendations for the diagnosis and treatment of ANCA-associated vasculitis: GPA/Wegener's granulomatosis, MPA/microscopic polyangiitis and EGPA/Churg-Strauss, by following this link :-
Apologies to anyone who has read my response on Facebook but I'm aware there are some mutually exclusive members. In each group.
Thanks for publishing this and especially to John for his contribution.
I'm sure everyone will agree that it's good to have more up to date recommendations on the management of AAV, especially as more recent research findings and better understanding of drug regimes have changed the way these vasculitides are now managed by most specialist vasculitis clinicians.
For the less informed consultant, it provides an excellent, evidence based reference and assuming it can be broadly disseminated then it may well save lives.
However, there are a few recommendations which surprise and to be honest, trouble me. [Please note I have (atypical) GPA and some of the regimes suggested would probably have proved fatal to me so my vested interest may be slightly skewed].
The RITUXIVAS trial demonstrated no difference in the efficacy of cyclophosphamide and Rituximab of inducing remission. Furthermore, the RAVE trial demonstrated that patients treated with the latter appear to be less prone to flares so I'm surprised the panel voted in favour of the former as first line treatment (100%/88%), especially as it has known carcinogenic risk.
The choice of Azathioprine as the preferred maintenance drug over Rituximab (94%/59%) also surprises me, although I appreciate there are no published papers on the comparative effectiveness of annual, full dose Rituximab yet. The MAINRITSAN study did however find a six-fold benefit in the 0.5 gram maintenance regime so the conclusion reached by the panel baffles me somewhat.
The most 'disturbing' outcome for me is the recommendation to stop Rituximab after two years of remission induction (see Figure 1). Again I appreciate no full-dose, long term trials have yet been published but as someone who receives an annual dose, I'd hate to think someone (especially in the hospital management accounting department) might use this as evidence to stop it as my maintenance treatment. I sincerely hope the days of 'stop and wait and see' are behind us.
I've only read the report once and also only on a mobile device so I hope I haven't misunderstood or misinterpreted any of the above.
I should also add these are my personal observations and are in no way criticisms of the excellent job the panel has done in bringing AAV management regimes up to date.
I'm looking forward to Dr Richard Watts' webinar and trust as many V-UK members with an interest will support the event.
Hi Martin , thought we had write the same reply as in the FB group too.
John here, remember these guidelines were drafted in March 2015 , the RITUXIVAS trial was an initial " non- inferiority" trial to demonstrate that RTX is at least as good as cyclophosphamide for induction. Even now, there is no clear evidence to give definitive advice on the use of RTX as a maintenance drug. It can be very frustrating to sit on one of these guideline panels because the bar for evidence is set so high and although one knows that the real world has moved on, if there is not the rock hard evidence to support any recommendations, then it is not allowed. It's rather like at the BSR conference DJ was expressing comments based on his informed opinion and experience, which all respect and to be honest, we believe, but DJ's opinion & experience is not evidence for the purpose of developing guidelines. Personally, I think the guidelines should be reviewed more frequently, but it is a costly and time consuming exercise. The fact that RTX is not recommended as a maintenance agent in the EULAR guidelines does not mean that it is prohibited or cannot be used. It is worth noting that, thanks to the intervention of Dr Peter Lanyon the NHS England guidance on the use of RTX is much more flexible. best wishes John
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