Concordance between practice and published evidence in the management of ANCA-associated vasculitis in Japan: A cross-sectional web-questionnaire survey

Differences in phenotypes, treatments, and outcomes of ANCA-associated vasculitis across Europe, Japan and the USA in 2020

OBJECTIVES

To clarify the differences in clinical phenotypes, therapeutic patterns, and outcomes of patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) across geographic regions using a multinational cohort.

METHODS

Data were collected from patients with newly diagnosed or relapsing GPA or MPA in Europe, Japan and the USA from January to July 2020. The composite outcome of kidney failure and/or death within 52 weeks after treatment was evaluated, and the hazard ratios across the regions were estimated using the Cox proportional hazard model. Heterogeneities of the effects were investigated via thorough subgroup analyses.

RESULTS

Among the 254 eligible patients (Europe, 137; Japan, 73; USA, 44), those in Japan were older and had higher proportions of MPO-ANCA positivity and lung involvement compared with Europe and the USA. The estimated glomerular filtration rate at diagnosis varied across regions, with the highest dialysis requirement in the USA. Cyclophosphamide and rituximab use were, respectively, 57% and 63% in Europe, 29% and 40% in Japan, and 34% and 86% in the USA. Within 52 weeks, 8%, 10% and 18% developed kidney failure, while 9%, 7% and 7% died in Europe, Japan, and the USA, respectively; and the composite outcome occurred in 15%, 14% and 23% of patients. The hazard ratios for kidney failure and/or death were comparable across regions; however, they varied among certain subgroups.

CONCLUSIONS

Although the kidney failure-free survival was comparable across continents, regional differences existed in clinical phenotypes and therapeutic patterns.

Effectiveness and Safety of Avacopan as a Combination Therapy with Glucocorticoids or Monotherapy in Patients with Microscopic Polyangiitis

We herein report three cases of microscopic polyangiitis (MPA). Two patients were administered avacopan in combination with glucocorticoid (GC), whereas one patient was treated with avacopan monotherapy; none of the patients were co-administered either rituximab or cyclophosphamide. The doses of GC were successfully reduced after the introduction of avacopan in the two patients, and the serum C-reactive protein levels decreased in the patient treated with avacopan monotherapy. Avacopan may therefore be effective either in combination with GC or as monotherapy, even for patients at a high risk of developing adverse effects when administered rituximab or cyclophosphamide.

Current Diagnosis and Treatment of Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis: A Review Including a Comparison of Characteristics in Europe and Japan

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a disease entity characterized by systemic vasculitis positive for ANCAs, which often leads to severe organ damage such as diffuse bronchoalveolar hemorrhage and rapidly progressive glomerulonephritis. It is known that the incidence and characteristics of AAV vary depending on region, and differences in the peak age of onset, the ratio of positive rates of MPO-ANCA to PR3-ANCA, and occurrence rates of GPA and MPA may have resulted in different approaches to clinical practice. It may also be necessary to modify therapeutic strategies according to ethnic factors. Avacopan is a therapeutic option recently recommended for the management of AAV; however, the rate of severe liver injuries associated with avacopan was reported to be relatively high in the Japanese population. In this review, we introduce current globally recognized knowledge on the diagnosis and treatment of AAV, including a comparison of patient characteristics and clinical practice between Europe and Japan obtained from the recent literature.

Real-world clinical decisions of physicians in the management of Takayasu arteritis and giant cell arteritis in Japan: A cross-sectional web questionnaire survey

OBJECTIVES

The aim is to access the real-world clinical management of physicians who treat Takayasu arteritis (TAK) and giant cell arteritis (GCA) after the publication of the Japanese Circulation Society (JCS) 2017 Guidelines for the Management of Vasculitis Syndrome.

METHODS

This descriptive, cross-sectional study utilized self-administered electronic questionnaires, which were answered in February 2022 by physicians treating TAK or GCA and registered with Macromill Inc.

RESULTS

The 329 survey respondents were enrolled. The 2017 JCS Guidelines were the most commonly referenced information source for resolving clinical questions, accessed by 70% of respondents. Ophthalmoscopy was performed in only 50% of patients with TAK and in 70% for GCA. The median percentages of patients who underwent 18F-fluorodeoxyglucose-positron emission tomography/computed tomography for TAK and GCA patients were 23% and 20% at diagnosis, respectively, and 10% each at follow-up within 12 months. Tocilizumab was the most frequently used medication in combination with glucocorticoids for both TAK and GCA, especially in remission induction therapy for relapsed patients.

CONCLUSIONS

The majority of physicians treating TAK and GCA referred to the 2017 JCS guidelines. This report clarified the current clinical practice for large vessel vasculitis in Japan, providing information for the next revision of the guidelines.

Clinical practice guidelines of the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis for the management of microscopic polyangiitis and granulomatosis with polyangiitis: The 2023 update - secondary publication

OBJECTIVE

To revise the 2017 clinical practice guidelines (CPG) for the management of microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) to reflect advancements in the field.

METHODS

Similar to the 2017 CPG, the Grading of Recommendations, Assessment, Development, and Evaluation system was adopted for this revision. The intended users of this CPG include patients diagnosed with MPA or GPA in Japan and their families and healthcare professionals, including specialists and non-specialists. Based on a scoping review, four clinical questions (CQs) of the 2017 guidelines were modified, and six new CQs were added.

RESULTS

We suggest a combination of glucocorticoid and cyclophosphamide or rituximab for remission induction therapy. In cases where cyclophosphamide or rituximab is used, we suggest the use of avacopan over high-dose glucocorticoid. Furthermore, we suggest against the use of plasma exchange in addition to the standard treatment in severe cases of MPA/GPA. Finally, we suggest the use of glucocorticoid and rituximab over glucocorticoid and azathioprine for remission maintenance therapy.

CONCLUSIONS

The recommendations have been updated based on patient preference, certainty of evidence, benefit and risk balance, and cost.