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Holle JU, Moosig F. [Update on treatment of ANCA-associated vasculitis]. Z Rheumatol 2024:10.1007/s00393-024-01548-1. [PMID: 39196354 DOI: 10.1007/s00393-024-01548-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 08/29/2024]
Abstract
This article summarizes the current guidelines and recommendations published by the European Alliance of Associations for Rheumatology (EULAR), the Kidney Disease Improving Global Outcomes (KDIGO) and the American College of Rheumatology (ACR). In addition to glucocorticoids (GC), treatment with biologics is nowadays an established option to treat Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis (AAV). Rituximab (RTX) is used for remission induction and maintenance in organ-threatening and non-organ-threatening granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). For eosinophilic GPA (EGPA) anti-interleukin 5 (IL5) strategies are an important component of treatment for remission induction and maintenance of refractory or relapsing non-organ-threatening diseases in conjunction with GC. The dosing of GC for remission induction in GPA and MPA is now lower than was previously used and additionally, avacopan is approved as a new GC-sparing medication for GPA and MPA over 52 weeks. Conventional strategies, such as cyclophosphamide (CYC) are important for remission induction in severe or refractory organ-threatening disease for all AAVs. The use of methotrexate (MTX) and azathioprine (AZA) is becoming less prominent. The most important unanswered questions in the treatment of AAVs are with respect to the duration of remission maintenance treatment and the individualized treatment guidance based on biomarkers.
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Affiliation(s)
- Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Kuhberg 5a-7, 24534, Neumünster, Deutschland.
- Rheumazentrum Schleswig-Holstein Mitte, Sophienblatt 13-17, 24103, Kiel, Deutschland.
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Kuhberg 5a-7, 24534, Neumünster, Deutschland
- Rheumazentrum Schleswig-Holstein Mitte, Sophienblatt 13-17, 24103, Kiel, Deutschland
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2
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Puéchal X. Update on targeted treatments for ANCA-associated vasculitis. Joint Bone Spine 2024; 92:105768. [PMID: 39089473 DOI: 10.1016/j.jbspin.2024.105768] [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: 02/24/2024] [Revised: 07/10/2024] [Accepted: 07/16/2024] [Indexed: 08/04/2024]
Abstract
Targeted therapy has revolutionized the management of ANCA-associated vasculitis (AAV) over the last fifteen years. Rituximab, an approved induction and maintenance agent for severe AAV, is no less effective than cyclophosphamide as induction therapy and particularly useful in relapsing or refractory disease, or in women. In patients with relapsing AAV, granulomatosis with polyangiitis or PR3-ANCA, it is more effective than cyclophosphamide. Rituximab maintenance is superior to the conventional immunosuppressive drugs that it replaces. Low-dose preemptive rituximab infusions are recommended every 6months for 18months, followed by re-evaluation to decide whether 4 additional biannual infusions should be administered, balancing the probability of relapse and the risk of serious infections on rituximab. A growing body of experimental and clinical data shows that C5a pathway inhibition is a promising therapeutic option for AAV, which could reduce glucocorticoids needs. Avacopan is a first approved oral C5A receptor antagonist, used when there is a high risk that glucocorticoids will cause serious adverse events. In eosinophilic granulomatosis with polyangiitis, the importance of IL-5 for eosinophil activation and survival led to evaluation and approval of mepolizumab, a humanized monoclonal antibody directed against IL-5. Mepolizumab showed a steroid-sparing effect. Its effectiveness in active vasculitis remains uncertain and is currently being evaluated. Benralizumab targeting the IL-5 receptor was recently shown to be noninferior to mepolizumab. Rituximab has had disappointing results in non-severe active vasculitis and is being evaluated as maintenance therapy. Plasma exchange is not indicated as first-line treatment but remains recommended when creatinine levels exceed 300μmol/L.
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Affiliation(s)
- Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance publique-Hôpitaux de Paris (AP-HP).Centre, Université Paris Cité, Paris, France; Institut Cochin, Inserm U1016, CNRS UMR 8104, Paris, France; French Vasculitis Study Group, Hôpital Cochin, Paris, France.
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Reggiani F, Stella M, Calatroni M, Sinico RA. Treatment strategies for ANCA-associated vasculitides: from standard protocols to future horizons. Expert Rev Clin Immunol 2024; 20:765-780. [PMID: 38445642 DOI: 10.1080/1744666x.2024.2326628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION ANCA-associated vasculitides (AAV), classified into granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis represent a group of disorders characterized by necrotizing vasculitis of small vessels, endothelial injury and tissue damage. The outcomes and prognosis of AAV have undergone significant changes with the introduction of glucocorticoids (GCs) and other immunosuppressants (cyclophosphamide, azathioprine, methotrexate, and mycophenolate mofetil). The enhanced understanding of pathogenesis has subsequently led to the incorporation into clinical practice of drugs targeting specific therapeutic targets. AREAS COVERED After an extensive literature search of Pubmed, Medline, Embase of the most recent evidence, we provide an overview of available treatments, highlighting how newer drugs have integrated into standard protocols. Our review also explores potential new therapeutic targets, including B cell depletion and inhibition, T cell inhibition, complement inhibition, and IL-5 and IgE inhibition. EXPERT OPINION There is hope that the new treatment targets currently under study in AAV may enable a faster and more lasting clinical response, ensuring the reduction of possible side effects from therapies. Moreover, numerous aspects necessitate further exploration in the future, such as tailoring of GCs, integration of GCs-sparing agents, efficacy of combination therapy, optimal maintenance therapy, to reduce organ-damage and improve quality of life.
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Affiliation(s)
- Francesco Reggiani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matteo Stella
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
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Jakes RW, Kwon N, Huynh L, Hwee J, Baylis L, Alfonso-Cristancho R, Du S, Khanal A, Duh MS, Terrier B. Burden of eosinophilic granulomatosis with polyangiitis in Europe. ERJ Open Res 2024; 10:00912-2023. [PMID: 39104949 PMCID: PMC11299011 DOI: 10.1183/23120541.00912-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/26/2024] [Indexed: 08/07/2024] Open
Abstract
Background and aims Real-world evidence characterising the burden of eosinophilic granulomatosis with polyangiitis (EGPA) in Europe is limited. The aim of this study was to characterise patients in a large European EGPA cohort. Methods This retrospective, non-interventional, longitudinal study (GSK ID: 214661) recruited cross-specialty physicians from France, Germany, Italy, Spain and the UK to conduct medical chart reviews for patients with a physician-confirmed diagnosis of EGPA. Patients were ≥12 years of age at diagnosis with ≥1 year of follow-up data from the first clinical visit with the physician (index date). Outcome measures collected from index date to end of follow-up included clinical manifestations and healthcare resource utilisation (HCRU). Results In total, 407 patient medical charts were reviewed by 204 physicians; median (interquartile range) duration of follow-up from index date was 2.2 (1.7-3.5) years. Most patients (73.5%) had asthma. Patients underwent multiple diagnostic assessments, and 74.9% received ≥3 different therapies between diagnosis and end of follow-up (98.8% oral corticosteroids, 63.9% immunosuppressive therapies, 45.5% biologics). During follow-up, 84.5% of patients experienced EGPA clinical manifestations; most were considered moderate or severe and commonly affected the lungs (55.8%; including lung infiltrates 25.8% and severe asthma 24.8%), ear, nose and throat (53.3%), and skin (41.8%). HCRU was substantial: 26.0% of patients made emergency department visits, 36.6% were hospitalised and 84.8% had outpatient visits. Conclusions These real-world data show that EGPA presents a substantial burden to patients and the healthcare system. Earlier and better differential diagnosis and appropriate treatment may help reduce incidence of clinical manifestations and HCRU.
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Affiliation(s)
| | - Namhee Kwon
- Clinical Sciences, Respiratory, GSK, London, UK
| | | | | | - Lee Baylis
- Global Medical Affairs, GSK, Durham, NC, USA
| | | | - Shawn Du
- Analysis Group, Inc., Boston, MA, USA
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Lorenzo Martínez MDC, Hidalgo Herranz Á, Ochoa Ruiz AM, Gutierrez Ruano B, Ruiz Esteban R, Campos Téllez S, Jareño Esteban JJ. Severe Eosinophilic Asthma and Severe Mixed Polyneuropathy: A Case of Eosinophilic Granulomatous Vasculitis With Polyangiitis and New Therapeutic Perspectives. OPEN RESPIRATORY ARCHIVES 2024; 6:100312. [PMID: 38560507 PMCID: PMC10981092 DOI: 10.1016/j.opresp.2024.100312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
| | - Ángela Hidalgo Herranz
- Respiratory Medicine Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
| | - Ana María Ochoa Ruiz
- Respiratory Medicine Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
| | | | - Raúl Ruiz Esteban
- Internal Medicine Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
| | - Sergio Campos Téllez
- Respiratory Medicine Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
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Nanzer AM, Maynard-Paquette AC, Alam V, Green L, Thomson L, Lam J, Fernandes M, Roxas C, d'Ancona G, Hearn A, Gates J, Agarwal S, Kent BD, Fernando M, D'Cruz DP, Hopkins C, Ismail TF, Dhariwal J, Jackson DJ. Long-Term Effectiveness of Benralizumab in Eosinophilic Granulomatosis With Polyangiitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:724-732. [PMID: 38211889 DOI: 10.1016/j.jaip.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystemic disease characterized by eosinophilic tissue inflammation. Benralizumab, an anti-IL-5 receptor (anti-IL-5R) monoclonal antibody, induces rapid depletion of eosinophils; its longer-term effect in EGPA is unknown. OBJECTIVE To assess the real-world effectiveness and clinical remission rates of anti-IL-5R therapy in EGPA. METHODS We performed a retrospective cohort analysis of patients with EGPA, who commenced treatment with benralizumab. Clinical remission, assessed at 1 year and 2 years after the initiation of benralizumab, was defined as an absence of active vasculitis (Birmingham Vasculitis Activity Score of 0) and an oral corticosteroid (OCS) dose of ≤4 mg/d of prednisolone. "Super-responders" were defined as patients in remission and free of any significant relapses (asthma or extrapulmonary) over the preceding 12 months. The corticosteroid-sparing capacity of benralizumab, patient-reported outcome measures, and characteristics associated with clinical remission and super-responder status were also analyzed. RESULTS A total of 70 patients completed at least 1 year of treatment with benralizumab, of whom 53 completed 2 years. Of 70 patients, 47 (67.1%) met the definition for clinical remission at 1 year, with a similar proportion in remission at 2 years. Excluding asthma-related relapses, 61 of 70 (87.1%) patients were relapse free at 1 year, and of the 53 who completed 2 years, 45 (84.9%) were relapse free. A total of 67.9% of patients no longer needed any OCS for disease control. No significant difference was seen between antineutrophilic cytoplasmic antibody (ANCA)-positive and ANCA-negative subgroups. CONCLUSIONS In this real-world setting of patients with EGPA, treatment with benralizumab was well tolerated and resulted in corticosteroid-free clinical remission for the majority of patients.
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Affiliation(s)
- Alexandra M Nanzer
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | | | - Vardah Alam
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Linda Green
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Louise Thomson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Jodie Lam
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Mariana Fernandes
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Cris Roxas
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Grainne d'Ancona
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Andrew Hearn
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Jessica Gates
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Sangita Agarwal
- Rheumatology Department, Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Brian D Kent
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Michelle Fernando
- Rheumatology Department, Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - David P D'Cruz
- Rheumatology Department, Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Claire Hopkins
- Department of Ear, Nose and Throat Surgery, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Tevfik F Ismail
- Department of Cardiology, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Jaideep Dhariwal
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom.
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Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 124] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Reggiani F, L’Imperio V, Calatroni M, Pagni F, Sinico RA. Renal involvement in eosinophilic granulomatosis with polyangiitis. Front Med (Lausanne) 2023; 10:1244651. [PMID: 37790127 PMCID: PMC10544898 DOI: 10.3389/fmed.2023.1244651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/05/2023] [Indexed: 10/05/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a necrotizing vasculitis, which typically affects small-to medium-sized blood vessels. It is characterized by the presence of tissue infiltrates rich in eosinophils, along with the formation of granulomatous lesions. About 40% of cases have positive anti-neutrophil cytoplasm antibodies (ANCA), with predominant perinuclear staining, and anti-myeloperoxidase (anti-MPO) specificity in about 65% of cases. Typical manifestations of EGPA include the late onset of asthma, nasal and sinus-related symptoms, peripheral neuropathy, and significant eosinophilia observed in the peripheral blood. In contrast to granulomatosis with polyangiitis and microscopic polyangiitis, renal involvement in EGPA is less frequent (about 25%) and poorly studied. Necrotizing pauci-immune crescentic glomerulonephritis is the most common renal presentation in patients with ANCA-positive EGPA. Although rarely, other forms of renal involvement may also be observed, such as eosinophilic interstitial nephritis, mesangial glomerulonephritis, membranous nephropathy, or focal sclerosis. A standardized treatment for EGPA with renal involvement has not been defined, however the survival and the renal outcomes are usually better than in the other ANCA-associated vasculitides. Nonetheless, kidney disease is an adverse prognostic factor for EGPA patients. Larger studies are required to better describe the renal involvement, in particular for patterns different from crescentic glomerulonephritis, and to favor the development of a consensual therapeutic approach. In this article, in addition to personal data, we will review recent findings on patient clinical phenotypes based on ANCA, genetics and the impact of biological drugs on disease management.
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Affiliation(s)
- Francesco Reggiani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Vincenzo L’Imperio
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS (Scientific Institute for Research, Hospitalization and Healthcare) Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS (Scientific Institute for Research, Hospitalization and Healthcare) Fondazione San Gerardo dei Tintori, Monza, Italy
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Mencarelli L, Moi L, Dewarrat N, Monti M, Alberio L, Ringwald M, Swierdzewska K, Panagiotis A, Ribi C. Eosinophilic Granulomatosis with Polyangiitis after mRNA-1273 SARS-CoV-2 Vaccine. Vaccines (Basel) 2023; 11:1335. [PMID: 37631903 PMCID: PMC10457893 DOI: 10.3390/vaccines11081335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
During one of the worst global health crises, millions of people were vaccinated against SARS-CoV-2. In rare cases, new onset systemic inflammatory diseases were reported with temporal coincidence to the vaccination. We describe a case of severe Eosinophilic Granulomatosis with Polyangiitis (EGPA) in a young asthmatic woman, occurring after a second dose of the mRNA-1273 vaccine. She presented with multisystem EGPA with cardiac and central nervous system involvement, complicated by secondary immune thrombocytopenia (ITP). We review the reported cases of EGPA coinciding with SARS-CoV-2 mRNA vaccination. All potentially vaccine-related EGPA cases reported so far occurred within 14 days from immunization. EGPA is very rare with an incidence of 1:1,000,000 inhabitants, and the number of reported post-vaccination EGPA cases lies within the expected incidence rate for the period. While we cannot prove a causal relationship between the vaccine and EGPA onset, the temporal relationship with the vaccine immune stimulation is intriguing, in a disease occurring almost always in adults with asthma and/or chronic rhinosinusitis and driven by an aberrant Th2 lymphocyte activation with hypereosinophilia; nevertheless, cases of inflammatory diseases (IMIDs) emerging in the context of vaccination remain rare and the benefits of preventing severe COVID presentations with SARS-CoV-2 mRNA vaccines remain unquestionable.
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Affiliation(s)
- Lucrezia Mencarelli
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital, Lausanne University, 1011 Lausanne, Switzerland
| | - Laura Moi
- Division of Immunology and Allergology, Institut Central des Hôpitaux du Valais, 1951 Sion, Switzerland
| | - Natacha Dewarrat
- Division of Haematology and Central Laboratory of Hematology, Lausanne University Hospital, Lausanne University, 1011 Lausanne, Switzerland
| | - Matteo Monti
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital, Lausanne University, 1011 Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Laboratory of Hematology, Lausanne University Hospital, Lausanne University, 1011 Lausanne, Switzerland
| | - Maxime Ringwald
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital, Lausanne University, 1011 Lausanne, Switzerland (C.R.)
| | - Karolina Swierdzewska
- Division of Diagnostic Radiology, Department of Radiology, Lausanne University Hospital, Lausanne University, 1011 Lausanne, Switzerland
| | - Antiochos Panagiotis
- Division of Cardiology, Department of Heart and Vessels, Lausanne University Hospital, Lausanne University, 1011 Lausanne, Switzerland
| | - Camillo Ribi
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital, Lausanne University, 1011 Lausanne, Switzerland (C.R.)
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10
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Bloom JL, Langford CA, Wechsler ME. Therapeutic Advances in Eosinophilic Granulomatosis with Polyangiitis. Rheum Dis Clin North Am 2023; 49:563-584. [PMID: 37331733 DOI: 10.1016/j.rdc.2023.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is an eosinophilic vasculitis that affects a variety of organ systems. Historically, glucocorticoids and a variety of other immunosuppressants were used to abrogate the inflammation and tissue injury associated with EGPA. The management of EGPA has evolved greatly during the last decade with the development of novel targeted therapeutics that have resulted in significantly improved outcomes for these patients, with many more novel targeted therapies emerging.
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Affiliation(s)
- Jessica L Bloom
- Section of Rheumatology, Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue B-311, Aurora, CO 80045, USA
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44195, USA
| | - Michael E Wechsler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, J215, 1400 Jackson Street, Denver, CO 80206, USA.
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11
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Magri SJ, Ugarte-Gil MF, Brance ML, Flores-Suárez LF, Fernández-Ávila DG, Scolnik M, Sato EI, de Souza AWS, Saldarriaga-Rivera LM, Babini AM, Zamora NV, Felquer MLA, Vergara F, Carlevaris L, Scarafia S, Guppy ERS, Unizony S. Pan American League of Associations for Rheumatology Guidelines for the treatment of ANCA-associated vasculitis. THE LANCET. RHEUMATOLOGY 2023; 5:e483-e494. [PMID: 38251580 DOI: 10.1016/s2665-9913(23)00128-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 01/23/2024]
Abstract
Considerable variability exists in the way health-care providers treat patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis in Latin America. The most frequently used treatments for ANCA-associated vasculitis are cyclophosphamide and prolonged glucocorticoid tapers; however, randomised controlled trials conducted over the past 30 years have led to the development of several evidence-based treatment alternatives for these patients. Latin America faces socioeconomic challenges that affect access to care, and the use of certain costly medications with proven efficacy ANCA-associated vasculitis is often restricted. For these reasons, the Pan American League of Associations for Rheumatology developed the first ANCA-associated vasculitis treatment guidelines tailored for Latin America. A panel of local vasculitis experts generated clinically meaningful questions related to the treatment of ANCA-associated vasculitis using the Population, Intervention, Comparator, and Outcome (PICO) format. Following the Grading of Recommendations Assessment, Development, and Evaluation methodology, a team of methodologists conducted a systematic literature review. The panel of vasculitis experts voted on each PICO question and made recommendations, which required at least 70% agreement among the voting members. 21 recommendations and two expert opinion statements for the treatment of ANCA-associated vasculitis were developed, considering the current evidence and the socioeconomic characteristics of the region. These recommendations include guidance for the use of glucocorticoids, non-glucocorticoid immunosuppressants, and plasma exchange.
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Affiliation(s)
- Sebastián Juan Magri
- Rheumatology Unit, Hospital Italiano de La Plata, La Plata, Buenos Aires, Argentina
| | | | | | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | | | - Marina Scolnik
- Rheumatology Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Emilia Inoue Sato
- Medicine Department, Universidad Federal de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Santiago Scarafia
- Rheumatology Unit, Hospital Municipal San Cayetano, Virreyes, Argentina
| | | | - Sebastian Unizony
- Vasculitis and Glomerulonephritis Center, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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12
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Khoury P, Akuthota P, Kwon N, Steinfeld J, Roufosse F. HES and EGPA: Two Sides of the Same Coin. Mayo Clin Proc 2023; 98:1054-1070. [PMID: 37419574 PMCID: PMC10348452 DOI: 10.1016/j.mayocp.2023.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/03/2023] [Accepted: 02/15/2023] [Indexed: 07/09/2023]
Abstract
Elevated eosinophil counts are implicated in multiple diseases, from relatively prevalent organ-specific disorders such as severe eosinophilic asthma, to rare multisystem disorders such as hypereosinophilic syndrome (HES) and eosinophilic granulomatosis with polyangiitis (EGPA). Patients with these multisystem diseases, often associated with markedly elevated eosinophil counts, have a substantial risk of morbidity and mortality due to delayed diagnosis or inadequate treatment. A thorough workup of symptomatic patients presenting with elevated eosinophil counts is essential, although in some cases the differential diagnosis may remain difficult because of overlapping presentations between HES and EGPA. Notably, first- and second-line treatment options and response to therapy may differ for specific HES and EGPA variants. Oral corticosteroids are the first line of treatment for HES and EGPA, except when HES is the result of specific mutations driving clonal eosinophilia that are amenable to targeted treatment with a kinase inhibitor. Cytotoxic or immunomodulatory agents may be required for those with severe disease. Novel eosinophil-depleting therapies, such as those targeting interleukin 5 or its receptor, have shown great promise in reducing blood eosinophil counts, and reducing disease flares and relapses in patients with HES and EGPA. Such therapies could reduce the side effects associated with long-term oral corticosteroids or immunosuppressant use. This review provides a pragmatic guide to approaching the diagnosis and clinical management of patients with systemic hypereosinophilic disorders. We highlight practical considerations for clinicians and present cases from real-world clinical practice to show the complexity and challenges associated with diagnosing and treating patients with HES and EGPA.
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Affiliation(s)
- Paneez Khoury
- Eosinophil Clinical Research Unit, LPD, National Institute of Health, Bethesda, MD, USA
| | | | - Namhee Kwon
- Respiratory Research & Development, GSK, GSK House, Brentford, Middlesex, UK
| | | | - Florence Roufosse
- Department of Internal Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
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13
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Emmi G, Bettiol A, Gelain E, Bajema IM, Berti A, Burns S, Cid MC, Cohen Tervaert JW, Cottin V, Durante E, Holle JU, Mahr AD, Del Pero MM, Marvisi C, Mills J, Moiseev S, Moosig F, Mukhtyar C, Neumann T, Olivotto I, Salvarani C, Seeliger B, Sinico RA, Taillé C, Terrier B, Venhoff N, Bertsias G, Guillevin L, Jayne DRW, Vaglio A. Evidence-Based Guideline for the diagnosis and management of eosinophilic granulomatosis with polyangiitis. Nat Rev Rheumatol 2023; 19:378-393. [PMID: 37161084 DOI: 10.1038/s41584-023-00958-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 05/11/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, characterized by asthma, eosinophilia and granulomatous or vasculitic involvement of several organs. The diagnosis and management of EGPA are often challenging and require an integrated, multidisciplinary approach. Current practice relies on recommendations and guidelines addressing the management of ANCA-associated vasculitis and not specifically developed for EGPA. Here, we present evidence-based, cross-discipline guidelines for the diagnosis and management of EGPA that reflect the substantial advances that have been made in the past few years in understanding the pathogenesis, clinical subphenotypes and differential diagnosis of the disease, as well as the availability of new treatment options. Developed by a panel of European experts on the basis of literature reviews and, where appropriate, expert opinion, the 16 statements and five overarching principles cover the diagnosis and staging, treatment, outcome and follow-up of EGPA. These recommendations are primarily intended to be used by healthcare professionals, pharmaceutical industries and drug regulatory authorities, to guide clinical practice and decision-making in EGPA. These guidelines are not intended to limit access to medications by healthcare agencies, nor to impose a fixed order on medication use.
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Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elena Gelain
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Ingeborg M Bajema
- Department of Pathology, Groningen University Medical Center, Groningen, the Netherlands
| | - Alvise Berti
- Rheumatology, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy
| | - Stella Burns
- Vasculitis and Lupus Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
- University of Barcelona. Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Jan W Cohen Tervaert
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, University of Lyon, IVPC, INRAE, ERN-LUNG, Lyon, France
| | - Eugenia Durante
- APACS, Associazione Pazienti con Sindrome di Churg Strauss, Arosio, Italy
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster/Kiel, Germany
| | - Alfred D Mahr
- Department of Rheumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marcos Martinez Del Pero
- Vasculitis and Lupus Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- ENT Department, West Suffolk Hospital, Bury St Edmunds, UK
| | - Chiara Marvisi
- Rheumatology Unit, Università di Modena e Reggio Emilia, Modena, Italy
| | | | - Sergey Moiseev
- Tareev Clinic of Internal Disease, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster/Kiel, Germany
| | - Chetan Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Thomas Neumann
- Department of Rheumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Iacopo Olivotto
- Meyer Children Hospital and Careggi University Hospital, University of Florence, Florence, Italy
| | - Carlo Salvarani
- Unit of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Department of Surgery, Medicine, Dentistry and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research, Hannover Medical School, Hannover, Germany
| | - Renato A Sinico
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
- Renal Unit, ASST-Monza, Monza, Italy
| | - Camille Taillé
- Reference center for rare respiratory diseases, Bichat Hospital, AP-HP-Nord, University Paris Cité, Paris, France
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Nils Venhoff
- Clinic for Rheumatology and Clinical Immunology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Crete, Greece
- Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP, University of Paris, Paris, France
| | - David R W Jayne
- University of Cambridge, Box 118, Addenbrooke's Hospital, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy.
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy.
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Fijolek J, Radzikowska E. Eosinophilic granulomatosis with polyangiitis - Advances in pathogenesis, diagnosis, and treatment. Front Med (Lausanne) 2023; 10:1145257. [PMID: 37215720 PMCID: PMC10193253 DOI: 10.3389/fmed.2023.1145257] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/13/2023] [Indexed: 05/24/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease characterized by eosinophil-rich granulomatous inflammation and necrotizing vasculitis, pre-dominantly affecting small-to-medium-sized vessels. It is categorized as a primary antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) but also shares features of hypereosinophilic syndrome (HES); therefore, both vessel inflammation and eosinophilic infiltration are suggested to cause organ damage. This dual nature of the disease causes variable clinical presentation. As a result, careful differentiation from mimicking conditions is needed, especially from HES, given the overlapping clinical, radiologic, and histologic features, and biomarker profile. EGPA also remains a diagnostic challenge, in part because of asthma, which may pre-dominate for years, and often requires chronic corticosteroids (CS), which can mask other disease features. The pathogenesis is still not fully understood, however, the interaction between eosinophils and lymphocytes B and T seems to play an important role. Furthermore, the role of ANCA is not clear, and only up to 40% of patients are ANCA-positive. Moreover, two ANCA-dependent clinically and genetically distinct subgroups have been identified. However, a gold standard test for establishing a diagnosis is not available. In practice, the disease is mainly diagnosed based on the clinical symptoms and results of non-invasive tests. The unmet needs include uniform diagnostic criteria and biomarkers to help distinguish EGPA from HESs. Despite its rarity, notable progress has been made in understanding the disease and in its management. A better understanding of the pathophysiology has provided new insights into the pathogenesis and therapeutic targets, which are reflected in novel biological agents. However, there remains an ongoing reliance on corticosteroid therapy. Therefore, there is a significant need for more effective and better-tolerated steroid-sparing treatment schemes.
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15
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Pagnoux C, Berti A. Advances in the pharmacotherapeutic management of eosinophilic granulomatosis with polyangiitis. Expert Opin Pharmacother 2023; 24:1269-1281. [PMID: 37204027 DOI: 10.1080/14656566.2023.2216379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/17/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare but potentially lethal systemic vasculitis. Only a few prospective therapeutic trials had been conducted in EGPA, and its treatment was mostly adapted from other vasculitides. Monoclonal antibodies inhibiting various pathways (e.g. interleukin-5 [IL5] or B cells) have been investigated. AREAS COVERED Published studies on treatments for EGPA using glucocorticoids, conventional immunosuppressants (such as cyclophosphamide or azathioprine), antiIL5 pathway agents (mepolizumab, approved by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) for EGPA; benralizumab and reslizumab), other and future possible treatments [PubMed search, 01/1990-02/2023] are reviewed. EXPERT OPINION With advances made in the pharmacotherapeutic management of EGPA, the prognosis has gradually shifted from a potentially fatal to a more chronic course, for which more targeted and safer treatments can be used. However, glucocorticoids remain central. Rituximab is now a possible alternative to cyclophosphamide for induction, although data are still limited. AntiIL5 pathway therapies have been shown to be safe and effective in relapsing patients with EGPA, who often experience asthma and/or ears, nose, and throat (ENT) manifestations, but long-term data are needed. Treatment strategies need to be optimized based on individual patient characteristics, likely with sequential, combination-based approaches, while topical airway treatments should not be forgotten.
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Affiliation(s)
- Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University Health Network, Toronto, Canada
- Canadian Vasculitis research network (CanVasc), Toronto, Ontario, Canada
| | - Alvise Berti
- Center for Medical Sciences (CISMed) and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy
- Rheumatology Unit, Santa Chiara Regional Hospital, Trento, APSS, Italy
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16
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Krol RM, Remmelts HHF, Klaasen R, Frima A, Hagen EC, Kamalski DMA, Heijstek MW, Spierings J. Systemic and Local Medical or Surgical Therapies for Ear, Nose and/or Throat Manifestations in ANCA-Associated Vasculitis: A Systematic Literature Review. J Clin Med 2023; 12:jcm12093173. [PMID: 37176613 PMCID: PMC10179364 DOI: 10.3390/jcm12093173] [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: 04/07/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Ear, nose and throat (ENT) manifestations are common in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), yet how to treat these manifestations remains controversial. Therefore, we systematically reviewed the literature on the efficacy of therapies on ENT manifestations in AAV. METHODS A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline, Embase and Cochrane libraries, including clinical studies between January 2005 and January 2022, in adults with AAV and ENT involvement, reporting on the effects of local and systemic therapy. The critical appraisal was performed using tools provided by the Cochrane Library and the level of evidence (LoE) was scored according to the Oxford Centre for Evidence-based Medicine. RESULTS After screening 5609 identified studies, 136 full-text articles were assessed. Finally, 31 articles were included for critical appraisal and data-extraction. Nearly all studies (n = 29) were retrospective and scored low on LoE. The included studies evaluated local interventions (n = 11), glucocorticoids combined with conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) (n = 8), rituximab (n = 6), or mepolizumab (n = 6). Due to heterogeneity across studies meta-analysis was not performed. Four studies on mepolizumab for sinonasal symptoms (n = 92) showed response in 33-100% and relapse in 35%. Local therapy for subglottic stenosis was effective in 80-100% of patients in 11 studies (n = 157), but relapses were common (up to 83%). In five studies, hearing improvement was observed in 56-100%, with better outcomes when glucocorticoids were combined with csDMARDs compared to glucocorticoids only. CONCLUSION Response rates of ENT manifestations varied widely in studies and relapses were observed frequently. Heterogeneity among studies impaired comparison.
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Affiliation(s)
- Roline M Krol
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Hilde H F Remmelts
- Department of Nephrology, Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
| | - Ruth Klaasen
- Department of Rheumatology, Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
| | - Annelies Frima
- Department of Otorhinolaryngology, Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
| | - E Christiaan Hagen
- Department of Nephrology, Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
| | - Digna M A Kamalski
- Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Marloes W Heijstek
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Julia Spierings
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
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Wechsler ME, Hellmich B, Cid MC, Jayne D, Tian X, Baylis L, Roufosse F. Unmet needs and evidence gaps in hypereosinophilic syndrome and eosinophilic granulomatosis with polyangiitis. J Allergy Clin Immunol 2023:S0091-6749(23)00334-2. [PMID: 37086239 DOI: 10.1016/j.jaci.2023.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/17/2023] [Accepted: 03/16/2023] [Indexed: 04/23/2023]
Abstract
Hypereosinophilic syndrome (HES) and eosinophilic granulomatosis with polyangiitis (EGPA) are rare systemic inflammatory disorders with overlapping symptoms, elevated eosinophil counts, and heterogenous clinical presentations. Although progress has been made in recent years, there are substantial gaps in our understanding of the pathologic mechanisms involved in these diseases, as well as numerous unmet needs relating to both diagnosis and patient management. For example, in most cases of HES, the underlying cause of hypereosinophilia is unknown, while in EGPA, although a polygenic genetic susceptibility has been found, understanding of the pathogenic mechanisms remains largely elusive. Delineating differences between certain disease variants may be challenging, and there are no reliable predictive markers of disease course. In addition, the current diagnostic criteria for HES and classification criteria for EGPA are not easy to implement in a nonspecialist setting, and specialist referral pathways need to be signposted more clearly. Furthermore, disease-specific activity scores need to be developed to aid the assessment of treatment effects, and improved biomarkers are needed to aid with treatment stratification. In this review, we outline the limitations of our current understanding of HES and EGPA and highlight areas for future work, which ultimately should help improve patient management and outcomes.
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Affiliation(s)
| | - Bernhard Hellmich
- Department of Medicine, Medius Kliniken, Academic Teaching Hospital, University of Tübingen, Kirchheim-Teck, Germany
| | - Maria C Cid
- Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Xinping Tian
- Peking Union Medical College Hospital, Beijing, China
| | | | - Florence Roufosse
- Department of Internal Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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18
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Paroli M, Gioia C, Accapezzato D. New Insights into Pathogenesis and Treatment of ANCA-Associated Vasculitis: Autoantibodies and Beyond. Antibodies (Basel) 2023; 12:antib12010025. [PMID: 36975372 PMCID: PMC10045085 DOI: 10.3390/antib12010025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a group of rare systemic diseases affecting small-caliber vessels. The damage caused by AAV mainly involves the lung and kidneys. AAV includes three different types: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Although the different phenotypic forms of AAV share common features, recent studies have shown that there are significant differences in terms of pathogenetic mechanisms involving both the adaptive and innate immune systems. Advances in our understanding of pathogenesis have enabled the development of immuno-targeted therapies. This review illustrates the characteristics of the various forms of AAV and the new therapies available for this disease that can have lethal consequences if left untreated.
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Affiliation(s)
- Marino Paroli
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Chiara Gioia
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
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Multiple Cutaneous Manifestations in ANCA-Positive Eosinophilic Granulomatosis with Polyangiitis before and after Biologic Therapy: Clinical and Histopathologic Characterization of a Paradigmatic Case. J Clin Med 2022; 11:jcm11247429. [PMID: 36556045 PMCID: PMC9782198 DOI: 10.3390/jcm11247429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare immune-mediated vasculitis associated with anti-neutrophil cytoplasmic antibodies (ANCAs). Having systemic and possibly severe involvement, a prompt recognition of its clinical features is crucial to achieve favorable patient outcomes. Although cutaneous manifestations represent key elements, these still remain poorly characterized. We report a case of ANCA-positive EGPA presenting with palpable purpura, livedo reticularis, and pemphigoid-like lesions that was successfully treated with glucocorticoid therapy and rituximab. This report portrays the evolution of cutaneous lesions in ANCA-positive EGPA and demonstrates how dermatologic signs may represent indicators of active disease, allowing for timely diagnosis and for the monitoring of disease activity during treatment.
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20
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Caproni M, Calabria VRD, Mariotti EB, Verdelli A, Aimo C, Corrà A, Quintarelli L, Volpi W, Alpsoy E, Sunderkötter C. The impact on the scientific community of the 2018 addendum to the CHCC. Front Med (Lausanne) 2022; 9:1081063. [DOI: 10.3389/fmed.2022.1081063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 12/02/2022] Open
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21
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Alam V, Nanzer AM. Eosinophilic granulomatosis with polyangiitis: case report and literature review. Breathe (Sheff) 2022; 18:220170. [PMID: 36865937 PMCID: PMC9973489 DOI: 10.1183/20734735.0170-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss syndrome, is a multisystem disorder characterised by asthma, blood and tissue eosinophilia and small-vessel vasculitis. Eosinophilic tissue infiltration and extravascular granuloma formation can lead to damage in any organ, but it is classically seen to cause pulmonary infiltrates, sino-nasal disease, peripheral neuropathy, renal and cardiac involvement, and rashes. EGPA is part of the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis syndromes, with the antibody being detected in ∼30-40% of cases and mostly against myeloperoxidase. Two genetically and clinically distinct phenotypes, defined by the presence or absence of ANCA have been identified. Treatment for EGPA focuses on inducing and maintaining disease remission. To date, oral corticosteroids remain first-line agents whilst second-line treatments include immunosuppressants such as cyclophosphamide, azathioprine, methotrexate, rituximab and mycophenolate mofetil. However, long-term steroid usage results in multiple and well-known adverse health effects and new insights into the pathophysiology of EGPA have allowed for the development of targeted biologic therapies, like the anti-eosinophilic, anti-interleukin-5 monoclonal antibodies.
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Affiliation(s)
- Vardah Alam
- Guy's and St Thomas’ Hospitals NHS Trust, London, UK,Corresponding author: Vardah Alam ()
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22
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Casal Moura M, Branco C, Martins-Martinho J, Ferraro JL, Berti A, Nogueira E, Ponte C. A glance into the future of anti-neutrophil cytoplasmic antibody-associated vasculitis. Ther Adv Musculoskelet Dis 2022; 14:1759720X221125979. [PMID: 36353270 PMCID: PMC9638684 DOI: 10.1177/1759720x221125979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/26/2022] [Indexed: 11/06/2022] Open
Abstract
In the past decade, unprecedented progress has been made in understanding the pathogenesis, diagnosis, assessment, and treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). International collaborations and input from several fields (e.g. immunology, rheumatology, and nephrology) have been critical for analyzing demographics, disease manifestations, and outcomes in clinical research studies. Such efforts opened new avenues for generating novel questions and rationale to design better clinical trials. In addition, clinical research has been a source of several biological discoveries and the starting point for knowledge seeking on the pathophysiology of AAV. Interestingly, the blending of clinical and basic research provides a platform for personalized medicine. Despite recent revisions on AAV classification, the incorporation of new findings on disease genetics and immunologic responses may soon result in changes in clinical practice. These advances will enhance the selection of more specific and targeted therapies. However, current unmet needs in the management of AAV are still sizable and heavily impact long-term survival. Especially, frequent relapses, damage accrual, and high morbidity contribute to poor outcomes. Finally, the lack of defined biomarkers for disease activity and the prognosis is a permanent challenge in AAV research. Our work provides an overview of the current state of the art in AAV literature and suggests bridges for the remaining knowledge gaps. It offers potential future directions for the clinical assessment, management, and research in the field toward a more personalized medicine approach.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo
Clinic College of Medicine and Science, 200 First Street, Rochester, MN
55905-0002, USA
- Department of Medicine, Faculty of Medicine,
Porto University, Porto, Portugal
| | - Carolina Branco
- Renal Transplant and Nephrology Department,
Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte,
Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa
Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de
Medicina de Lisboa, Lisbon, Portugal
| | - José Luís Ferraro
- Rheumatology Department, Hospital de Santa
Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de
Medicina de Lisboa, Lisbon, Portugal
| | - Alvise Berti
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo
Clinic College of Medicine and Science, Rochester, MN, USA
- Rheumatology Department, Santa Chiara Hospital
and Department of Cellular, Computational and Integrative Biology (CIBIO),
University of Trento, Trento, Italy
| | - Estela Nogueira
- Renal Transplant and Nephrology Department,
Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte,
Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa
Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de
Medicina de Lisboa, Lisbon, Portugal
- Unidade de Investigação em Reumatologia,
Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de
Lisboa, Lisbon, Portugal
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23
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Bond M, Fagni F, Moretti M, Bello F, Egan A, Vaglio A, Emmi G, Dejaco C. At the Heart of Eosinophilic Granulomatosis with Polyangiitis: into Cardiac and Vascular Involvement. Curr Rheumatol Rep 2022; 24:337-351. [PMID: 36194339 DOI: 10.1007/s11926-022-01087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of existing literature on pathogenetic and clinical aspects of cardiac and vascular involvement in eosinophilic granulomatosis with polyangiitis (EGPA). RECENT FINDINGS In EGPA, cardiac and vascular involvement are more common than previously thought. However, no international recommendations on the topic are available yet. Herein, we summarize the existing evidence on the topic and propose a diagnostic approach for cardiac involvement in EGPA. The prevalence of cardiovascular involvement in patients with EGPA varies greatly among published studies, ranging between 3.1-18.7% for occlusive arterial disease, 5.8-30% for venous thrombosis and 17-92% for heart involvement. Cardiac involvement in EGPA is associated with high mortality even though manifestations are heterogeneous. In principle, every anatomical structure of the heart can be involved, and EGPA-related heart disease may be completely asymptomatic at first. A careful diagnostic work-up for early detection and prompt treatment initiation is therefore required. While cardiac manifestations are more common in anti-neutrophil cytoplasmic antibodies (ANCA)-negative patients, arterial and venous thrombotic events are not linked to ANCA status but correlate closely with disease activity and accumulate at disease onset. Thrombotic events (mainly venous) are considerably more frequent in EGPA than in the general population contributing substantially to morbidity and highlighting the importance of developing specific prevention strategies for patients who are diagnosed with EGPA.
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Affiliation(s)
- Milena Bond
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy
| | - Filippo Fagni
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Michele Moretti
- Department of Cardiology - Azienda Provinciale Per I Servizi Sanitari Di Trento, Trento, Italy
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Allyson Egan
- Vasculitis & Lupus Unit, Department of Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.,Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy. .,Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria.
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24
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Abstract
This review aims to describe the epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment, and prognosis of eosinophilic granulomatosis with polyangiitis (EGPA). Eosinophilic granulomatosis with polyangiitis is a small to medium vessel necrotizing vasculitis, typically classified with granulomatosis with polyangiitis (GPA) and microscopic polyangitis (MPA) as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). However, less than 50% of patients with EGPA have a positive ANCA test. Among all the vasculitides, asthma and eosinophilia are unique features of EGPA. Eosinophilic granulomatosis with polyangiitis is very rare and the diagnosis may be missed as the disease evolves over time. Polyneuropathies are common and may be severe, requiring aggressive immunosuppressive therapy. Heart involvement is the most common cause of death in EGPA. Biopsy of involved tissue supports a clinically suspected diagnosis but is not always feasible. Treatment of EGPA is primarily dictated by the severity of disease and prognostic factors. More severe disease frequently requires the use of aggressive therapy such as cyclophosphamide. Once treatment is initiated, patients can achieve good control of symptoms; unfortunately, disease relapses are common and prolonged treatment with corticosteroids is often necessary for asthma management. A better understanding of the disease heterogeneity is needed for the development of better therapies.
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Affiliation(s)
- Alexandra Villa-Forte
- Cleveland Clinic - Center for Vasculitis Care and Research, Department of Rheumatic and Immunologic Diseases 9500 Euclid Ave/A50 Cleveland Ohio 44195-5243, USA
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25
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Trivioli G, Marquez A, Martorana D, Tesi M, Kronbichler A, Lyons PA, Vaglio A. Genetics of ANCA-associated vasculitis: role in pathogenesis, classification and management. Nat Rev Rheumatol 2022; 18:559-574. [PMID: 36109667 DOI: 10.1038/s41584-022-00819-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 12/15/2022]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) comprises granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), that share features of pauci-immune small-vessel vasculitis and the positivity of ANCA targeting proteinase-3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). AAV syndromes are rare, complex diseases and their aetio-pathogenesis is mainly driven by the interaction between environmental and genetic factors. In patients with GPA and MPA, the genetic associations are stronger with ANCA specificity (PR3- versus MPO-ANCA) than with the clinical diagnosis, which, in keeping with the known clinical and prognostic differences between PR3-ANCA-positive and MPO-ANCA-positive patients, supports an ANCA-based re-classification of these disorders. EGPA is also made up of genetically distinct subsets, which can be stratified on ANCA-status (MPO ANCA-positive versus ANCA-negative); these subsets differ in clinical phenotype and possibly in their response to treatment. Interestingly, MPO-ANCA-positive patients with either MPA or EGPA have overlapping genetic determinants, thus strengthening the concept that this EGPA subset is closely related to the other AAV syndromes. The genetics of AAV provides us with essential information to understand its varied phenotype. This Review discusses the main findings of genetic association studies in AAV, their pathogenic implications and their potential effect on classification, management and prognosis.
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Affiliation(s)
- Giorgio Trivioli
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Ana Marquez
- Institute of Parasitology and Biomedicine "López-Neyra", CSIC, Granada, Spain
| | - Davide Martorana
- Medical Genetics Unit, Department of Diagnostics, University Hospital of Parma, Parma, Italy
- CoreLab Unit, Research Center, University Hospital of Parma, Parma, Italy
| | - Michelangelo Tesi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Vasculitis and Lupus Service, Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, UK
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy.
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.
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26
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Burchett JR, Dailey JM, Kee SA, Pryor DT, Kotha A, Kankaria RA, Straus DB, Ryan JJ. Targeting Mast Cells in Allergic Disease: Current Therapies and Drug Repurposing. Cells 2022; 11:3031. [PMID: 36230993 PMCID: PMC9564111 DOI: 10.3390/cells11193031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/31/2022] [Accepted: 09/20/2022] [Indexed: 11/22/2022] Open
Abstract
The incidence of allergic disease has grown tremendously in the past three generations. While current treatments are effective for some, there is considerable unmet need. Mast cells are critical effectors of allergic inflammation. Their secreted mediators and the receptors for these mediators have long been the target of allergy therapy. Recent drugs have moved a step earlier in mast cell activation, blocking IgE, IL-4, and IL-13 interactions with their receptors. In this review, we summarize the latest therapies targeting mast cells as well as new drugs in clinical trials. In addition, we offer support for repurposing FDA-approved drugs to target mast cells in new ways. With a multitude of highly selective drugs available for cancer, autoimmunity, and metabolic disorders, drug repurposing offers optimism for the future of allergy therapy.
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Affiliation(s)
| | | | | | | | | | | | | | - John J. Ryan
- Department of Biology, Virginia Commonwealth University, Richmond, VA 23284, USA
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27
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Abstract
PURPOSE OF REVIEW In recent years, therapeutic advances in eosinophilic granulomatosis with polyangiitis (EGPA) have changed our treatment paradigm. This review will summarize and discuss updates in management of EGPA, with a particular focus on biologic therapies. RECENT FINDINGS The anti-interleukin (IL)-5 agent mepolizumab (the first FDA-approved drug specifically for EGPA) is effective in induction and maintenance of remission particularly in patients with predominantly asthma and allergic manifestations, though efficacy in ANCA-positive, vasculitic disease is unclear; additional anti-IL-5 agents are under study. Rituximab is currently recommended for remission induction in severe disease, particularly in ANCA-positive patients with vasculitic manifestations, though the supportive evidence is mostly observational. Evidence supporting use of traditional DMARDs and other biologic agents such as omalizumab remains limited and observational. SUMMARY Although management of this heterogeneous disease remains challenging and unanswered questions remain, advances in biologics (particularly anti-IL-5 agents and an evolving interest in rituximab) have expanded our treatment armamentarium in EGPA.
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28
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Adachi S, Oshikata C, Kaneko T, Tsurikisawa N. Rituximab and dupilumab improve eosinophilic granulomatosis with polyangiitis with multiple pulmonary thrombi. Allergy Asthma Clin Immunol 2022; 18:18. [PMID: 35219344 PMCID: PMC8882302 DOI: 10.1186/s13223-021-00639-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022] Open
Abstract
Background Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by a necrotizing vasculitis with tissue and peripheral blood eosinophilia affecting small and medium-sized arteries, capillaries, and veins. Venous thromboembolic events are uncommon in EGPA. Moreover, there are only a few reported cases of EGPA complicated by pulmonary embolism or infarction. Case presentation We report the case of a 43-year-old woman with eosinophilic granulomatosis with polyangiitis and acute respiratory and heart failure due to bilateral pulmonary artery thrombosis and left femoral vein thrombosis 12 years after disease onset. She also had cardiac involvement (myocarditis, pericardial effusion, and diastolic dysfunction), gastrointestinal symptoms, and peripheral neuropathy. The condition was refractory to treatment with systemic corticosteroids, intravenous cyclophosphamide, and mepolizumab, but the thrombosis and associated acute cardiac failure, as well as the cardiac and gastrointestinal symptoms and multiple polyneuropathy, improved after a switch to rituximab. However, the heart failure did not improve sufficiently and the patient continued to need inhaled oxygen at 1 L/min and asthma exacerbations occurred. We then swapped the patient’s mepolizumab treatment for dupilumab. Not only did she have no further asthma attacks after switching to dupilumab, but also her vasculitis symptoms improved. Oxygen therapy was discontinued as the heart failure improved 5 months after starting the dupilumab. Conclusions This may be the first case report of the successful treatment by rituximab of pulmonary thromboembolism associated with EGPA. In addition, in this patient, treatment with dupilumab was effective not only for the asthma symptoms but also for the symptoms of vasculitis and heart failure.
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Affiliation(s)
- Sei Adachi
- Department of Allergy and Respirology, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan
| | - Chiyako Oshikata
- Department of Allergy and Respirology, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan.,Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Naomi Tsurikisawa
- Department of Allergy and Respirology, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan. .,Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
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29
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Suresh E. The management of anti-neutrophil cytoplasmic antibody-associated vasculitis: what has changed in the last 10 years? Br J Hosp Med (Lond) 2022; 83:1-10. [DOI: 10.12968/hmed.2021.0528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The management of anti-neutrophil cytoplasmic antibody-associated vasculitis has substantially improved in the last decade. For the induction of remission, rituximab is increasingly used in place of cyclophosphamide, particularly for patients with proteinase 3 (PR3)-associated vasculitis or relapsing disease, and those wishing to preserve their fertility. A lower dose regimen of glucocorticoids, with a more rapidly tapering schedule, is preferable and is as effective and safer than the standard-dose regimen. Avacopan, the complement C5a receptor inhibitor, is effective in the treatment of associated vasculitis and may replace glucocorticoids in the future. Plasma exchange provides no additional benefit for patients with severe anti-neutrophil cytoplasmic antibody-associated vasculitis, although it is still used in selected patients on a case-by-case basis. Rituximab is preferred for the maintenance of remission, repeated at fixed time intervals. The duration for which immunosuppressive therapy should be given is uncertain, but is generally longer for patients with PR3 disease or persistent anti-neutrophil cytoplasmic antibody positivity. The anti-interleukin 5 monoclonal antibody, mepolizumab, is effective for the treatment of non-severe eosinophilic granulomatosis with polyangiitis. Several other targeted therapies are in the pipeline and further progress is expected in the coming years.
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30
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Hellmich B, Holle J, Moosig F. [Eosinophilic granulomatosis with polyangiitis : Update on classification and management]. Z Rheumatol 2022; 81:286-299. [PMID: 35075511 DOI: 10.1007/s00393-021-01153-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 02/07/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare chronic inflammatory systemic disease that occurs in patients with bronchial asthma and is associated with significant blood and tissue eosinophilia. Another characteristic is vasculitis of small and/or medium-sized vessels, which may be absent in prodromal stages of the disease and is therefore no longer an obligatory part of the disease definition. Antineutrophil cytoplasmic antibodies (ANCA) can be detected in approximately one third of patients. The ANCA-positive and ANCA-negative EGPA are genetically distinct diseases with common clinical manifestations, which, however, occur with different frequencies. Cardiac involvement is associated with a poor prognosis. Permanent organ damage often occurs as a result of the underlying disease or treatment, especially with glucocorticoids (GC). The standard treatment of EGPA consists of GC in combination with cyclophosphamide for severe organ involvement or medium potency immunosuppressants for more prognostically favorable manifestations. Biologics are increasingly being used in the treatment of EGPA. The interleukin (IL) 5 antagonist mepolizumab reduces the risk of relapses and decreases the demand for GC in patients with relapsing EGPA without severe organ involvement. In analogy to the approach to other ANCA-associated vasculitides, the use of rituximab in ANCA-positive EGPA patients with severe vasculitis recurrence is a possible option, even though formal evidence for such an approach is currently low and formal approval is lacking.
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Affiliation(s)
- Bernhard Hellmich
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus der Universität Tübingen, Eugenstr. 3, 73230, Kirchheim unter Teck, Deutschland.
| | - Julia Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
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31
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Hellmich B, Henes JC. [Biologics for connective tissue diseases and vasculitides]. Internist (Berl) 2022; 63:143-154. [PMID: 35029701 DOI: 10.1007/s00108-021-01249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 12/04/2022]
Abstract
Despite therapy with glucocorticoids (GC) and conventional immunosuppressants, patients with connective tissue diseases and vasculitides often develop functionally relevant and prognostically unfavourable internal organ damage. Based on new pathogenetic insights, biologics and small molecules have recently been studied as targeted therapies for collagen vascular diseases and vasculitides. The B lymphocyte stimulator antagonist belimumab has been used for the treatment of systemic lupus erythematosus (SLE) for several years and has recently also been approved as an add-on therapy for lupus nephritis. Anifrolumab, an antibody against the type‑1 interferon receptor, has also been shown to be effective in phase III trials for the treatment of SLE. The interleukin (IL)-6-antagonist tocilizumab showed efficacy in the treatment of interstitial lung disease (ILD) in systemic sclerosis (SSc) and thus has been approved in the USA, although the phase III trial had a negative primary endpoint. In Europe the tyrosine inhibitor nintedanib is approved for progressive ILD in SSc. Tocilizumab is approved for the treatment of giant cell arteritis and reduces both the risk of recurrence and the cumulative GC requirement. The B‑lymphocyte depleting antibody rituximab is approved for induction and maintenance therapy of granulomatosis with polyangiitis and microscopic polyangiitis (MPA) and is currently also being investigated for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA). In patients with EGPA, the IL‑5 antibody mepolizumab leads to improved disease control and reduces GC requirements. A phase III trial of the small molecule antagonist avacopan targeting the complement C5a receptor as a replacement for high-dose GC in induction therapy of GPA and MPA met its primary endpoints. Various other biologics and small molecule antagonists are currently in clinical development for several type of vasculitis and collagen vascular diseases, some of them at advanced stages.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, medius Kliniken, Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland.
- Vaskulitiszentrum-Süd, Tübingen & Kirchheim-Teck, Deutschland.
| | - Joerg C Henes
- Zentrum für Interdisziplinäre Klinische Immunologie, Rheumatologie und Autoimmunerkrankungen (INDIRA), Universitätsklinikum Tübingen, Tübingen, Deutschland
- Medizinische Klinik II (Onkologie, Hämatologie, Klinische Immunologie und Rheumatologie), Universitätsklinikum Tübingen, Tübingen, Deutschland
- Vaskulitiszentrum-Süd, Tübingen & Kirchheim-Teck, Deutschland
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32
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Chen Y, Kuo P. Switching from omalizumab to mepolizumab therapy improved extra-pulmonary abdominal and cutaneous vasculitis symptoms in a patient with eosinophilic granulomatosis with polyangiitis. Respirol Case Rep 2022; 10:e0878. [PMID: 34876987 PMCID: PMC8629745 DOI: 10.1002/rcr2.878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/14/2021] [Accepted: 11/08/2021] [Indexed: 11/27/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis of small-to-medium-sized vessels. Both eosinophilic infiltration and vasculitis are thought to contribute to multi-organ damage. Some biologics have been used to reduce the required dose of corticosteroids in EGPA, but no single agent can ensure a complete control of this disease. Here, we describe a patient with anti-neutrophil cytoplasmic antibodies-negative relapsing EGPA whose asthma control was improved by omalizumab, but she continued to develop flares of abdominal and cutaneous vasculitis symptoms. After switching to mepolizumab therapy, her blood hypereosinophilia and extra-pulmonary symptoms were significantly improved. Moreover, the dose of daily maintenance corticosteroid could be tapered off. The experience from our case suggests that biologics targeting interleukin-5 may be more effective than omalizumab in the management of extra-thoracic manifestations in EGPA.
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Affiliation(s)
- Yu‐Hsuan Chen
- Department of Internal MedicineNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
| | - Ping‐Hung Kuo
- Department of Internal MedicineNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
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33
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Delcros Q, Groh M, Nasser M, Kahn JE, Cottin V. Steroid alternatives for managing eosinophilic lung diseases. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.2003777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Quentin Delcros
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine Hôpital Foch, Suresnes, France
| | - Matthieu Groh
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine Hôpital Foch, Suresnes, France
| | - Mouhamad Nasser
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases (Orphalung), Louis Pradel Hospital, Hospices Civils De Lyon, and Claude Bernard University Lyon 1, IVPC, Member of OrphaLung, RespiFIL and ERN-lung, France
| | - Jean-Emmanuel Kahn
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine, Hôpital Ambroise Paré, Université Paris Saclay, Assistance Publique Hôpitaux De Paris, Boulogne-Billancourt, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases (Orphalung), Louis Pradel Hospital, Hospices Civils De Lyon, and Claude Bernard University Lyon 1, IVPC, Member of OrphaLung, RespiFIL and ERN-lung, France
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34
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Uzzo M, Regola F, Trezzi B, Toniati P, Franceschini F, Sinico RA. Novel Targets for Drug Use in Eosinophilic Granulomatosis With Polyangiitis. Front Med (Lausanne) 2021; 8:754434. [PMID: 34796188 PMCID: PMC8593004 DOI: 10.3389/fmed.2021.754434] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
Abstract
Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a rare autoimmune disease characterized by medium and small vessels inflammation. Cardiac vasculitic involvement is one of the most severe manifestations with a significant impact on patients' long-term prognosis: anyway, a specific therapeutic approach for heart involvement in EGPA has not been explored yet. Current regimen consists of a long-term therapy with high dose of glucocorticoids, causing the well-known related-adverse events; immunosuppressive drugs are used in patients with severe manifestations, with some limitations. New therapeutic approaches are needed for patients with refractory disease or contraindications to conventional therapies. The quest for the ideal therapy is going toward a more and more personalized approach: on the one hand, efforts are made to use already existing therapies in the most appropriate way; on the other hand, new insights into EGPA pathogenesis allow the discovery of new targets, as demonstrated by mepolizumab and rituximab, targeting eosinophils, and B-cell compartments. This review summarizes the emerging therapies used in EGPA, focusing on the most recent studies on biologics and analyzing their efficacy and safety.
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Affiliation(s)
- Martina Uzzo
- Department of Clinical and Experimental Sciences, University of Milano-Bicocca, Monza, Italy.,Nephrology and Dialysis Unit, Ospedale San Gerardo di Monza, Monza, Italy
| | - Francesca Regola
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Barbara Trezzi
- Department of Clinical and Experimental Sciences, University of Milano-Bicocca, Monza, Italy.,Nephrology and Dialysis Unit, Ospedale San Gerardo di Monza, Monza, Italy
| | - Paola Toniati
- Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Franco Franceschini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Renato Alberto Sinico
- Department of Clinical and Experimental Sciences, University of Milano-Bicocca, Monza, Italy.,Nephrology and Dialysis Unit, Ospedale San Gerardo di Monza, Monza, Italy
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35
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Moosig F, Holle JU. [ANCA-associated vasculitis]. Dtsch Med Wochenschr 2021; 146:1287-1290. [PMID: 34553355 DOI: 10.1055/a-1308-5732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
GPA/MPA INDUCTION OF REMISSION As demonstrated in the ADVOCATE-trial avacopan allows for a substantial reduction of glucocorticoid (GC) use during induction of remission. A future role of avacopan in the treatment of GPA and MPA is likely. Likewise, the PEXIVAS-trial showed that GC reduction of up to 60 % compared to standard dose was equal effective. The same trial proved no benefit of plasma exchange in addition to standard induction of remission. Plasma exchange therefore is now mostly obsolete. GPA/MPA MAINTENANCE Rituximab is well established as maintenance therapy in AAV. The optimal duration however is still unknown. The MAINRITSAN 3 study indicates that prolonged use of more than 2 years is beneficial. EGPA: In line with earlier clinical evidence a GWAS including 534 EGPA patients indicated at last 2 distinct subgroups. The conception of a predominantly "vasculitis" and a more "eosinophilic" phenotype is supported by this genetic evidence and most likely will lead to more differentiated therapies. With the IL5-antibody mepolizumab a first principle targeting the eosinophilic component of EGPA is now available and proved to be clinically beneficial.
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Affiliation(s)
- Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster
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36
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Higashitani K, Yoshimi R, Sato Y, Watanabe T, Ihata A. Rituximab and Mepolizumab Combination Therapy for Glucocorticoid-Resistant Myocarditis Related to Eosinophilic Granulomatosis With Polyangiitis. Mod Rheumatol Case Rep 2021; 6:87-92. [PMID: 34473835 DOI: 10.1093/mrcr/rxab022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/30/2021] [Indexed: 01/30/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), which belongs to the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides, is characterized by eosinophil-rich granulomatous inflammation and small to medium-sized vessel vasculitis associated with bronchial asthma and eosinophilia. It sometimes causes severe organ damage, of which myocardial damage is one of the most important for determining the prognosis. A case of EGPA-associated myocarditis that was refractory to glucocorticoid therapy and responded successfully to rituximab (RTX) and mepolizumab (MPZ) combination therapy is presented. A 46-year-old woman was diagnosed with EGPA-associated myocarditis due to pre-existing asthma, eosinophilia, mononeuritis multiplex, and eosinophilic myocarditis by myocardial biopsy. Transthoracic echocardiography showed thickening of the cardiac wall, pericardial effusion, and left ventricular hypokinesis. Although the myocarditis was refractory to methylprednisolone pulse therapy followed by oral high-dose prednisolone, the disease activity reached remission with the successful tapering of glucocorticoid after initiation of the RTX and MPZ combination therapy. Combination therapy with RTX and MPZ can be a good treatment option for EGPA-associated myocarditis for which it is difficult to give intravenous cyclophosphamide due to cardiac dysfunction.
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Affiliation(s)
- Kana Higashitani
- Department of Rheumatology, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan.,Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Yuichiro Sato
- Department of Rheumatology, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan.,Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Toshiyuki Watanabe
- Department of Rheumatology, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan
| | - Atsushi Ihata
- Department of Rheumatology, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan
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37
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Mutoh T, Shirai T, Sato H, Fujii H, Ishii T, Harigae H. Multi-targeted therapy for refractory eosinophilic granulomatosis with polyangiitis characterized by intracerebral hemorrhage and cardiomyopathy: a case-based review. Rheumatol Int 2021; 42:2069-2076. [PMID: 34287685 DOI: 10.1007/s00296-021-04950-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/13/2021] [Indexed: 12/15/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic autoimmune disorder classified under anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, predominantly affecting small- to medium-sized vessels, characterized by asthma, eosinophilia, and necrotizing granulomatous inflammation. Most patients with EGPA experience peripheral neuropathy, whereas intracerebral hemorrhage is rare as EGPA-related presentation in central nervous system involvement, causing severe morbidity and mortality. Here, we present a 45-year-old man with refractory EGPA who developed intracerebral hemorrhage as the first manifestation, followed by cardiac involvement. This patient with a history of bronchial asthma developed a right putaminal hemorrhage caused by EGPA. Although intravenous cyclophosphamide (IVCY) and mepolizumab (MPZ) induced remission, relapse was frequently observed. Subsequently, he developed cardiomyopathy despite administration of rituximab (RTX) substituted from IVCY and MPZ. Combined immunosuppressive therapy, including IVCY, MPZ, and RTX was required to inhibit vascular inflammation, leading to sustained remission. We review previously published literature while focusing on the clinical features of patients with intracerebral hemorrhage caused by EGPA and describe clinical characteristics for detecting EGPA in patients with intracerebral hemorrhage, emphasizing rapid evaluation and recognition of EGPA and adequate intervention in the early vasculitic phase of this disease. We also refer to the immunological aspects of this case. It is important to consider "multi-targeted therapy" through interleukin-5 suppression and B cell depletion in the management of refractory EGPA.
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Affiliation(s)
- Tomoyuki Mutoh
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan.
| | - Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hiroko Sato
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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38
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Chung SA, Langford CA, Maz M, Abril A, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2021; 73:1088-1105. [PMID: 34235880 DOI: 10.1002/acr.24634] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Clinical questions regarding the treatment and management of AAV were developed in the population, intervention, comparator, and outcome (PICO) format (47 for GPA/MPA, 34 for EGPA). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 26 recommendations and 5 ungraded position statements for GPA/MPA, and 15 recommendations and 5 ungraded position statements for EGPA. This guideline provides recommendations for remission induction and maintenance therapy as well as adjunctive treatment strategies in GPA, MPA, and EGPA. These recommendations include the use of rituximab for remission induction and maintenance in severe GPA and MPA and the use of mepolizumab in nonsevere EGPA. All recommendations are conditional due in part to the lack of multiple randomized controlled trials and/or low-quality evidence supporting the recommendations. CONCLUSION This guideline presents the first recommendations endorsed by the American College of Rheumatology and the Vasculitis Foundation for the management of AAV and provides guidance to health care professionals on how to treat these diseases.
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Affiliation(s)
| | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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39
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Chung SA, Langford CA, Maz M, Abril A, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2021; 73:1366-1383. [PMID: 34235894 DOI: 10.1002/art.41773] [Citation(s) in RCA: 232] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Clinical questions regarding the treatment and management of AAV were developed in the population, intervention, comparator, and outcome (PICO) format (47 for GPA/MPA, 34 for EGPA). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 26 recommendations and 5 ungraded position statements for GPA/MPA, and 15 recommendations and 5 ungraded position statements for EGPA. This guideline provides recommendations for remission induction and maintenance therapy as well as adjunctive treatment strategies in GPA, MPA, and EGPA. These recommendations include the use of rituximab for remission induction and maintenance in severe GPA and MPA and the use of mepolizumab in nonsevere EGPA. All recommendations are conditional due in part to the lack of multiple randomized controlled trials and/or low-quality evidence supporting the recommendations. CONCLUSION This guideline presents the first recommendations endorsed by the American College of Rheumatology and the Vasculitis Foundation for the management of AAV and provides guidance to health care professionals on how to treat these diseases.
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Affiliation(s)
| | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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40
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New therapeutic strategies in lung vasculitis. Curr Opin Pulm Med 2021; 26:496-506. [PMID: 32740376 DOI: 10.1097/mcp.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To summarize the latest publications and provide a practical overview of treatment strategies for lung vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs). RECENT FINDINGS In patients with severe ANCA-associated vasculitis, plasma exchange, as adjunctive therapy to standard treatment, is not associated with improved survival or reduced risk of end-stage kidney disease. A regimen with reduced dose of glucocorticoids is equally effective to induce remission as a standard regimen. In patients without organ or life-threatening disease, mycophenolate mofetil can be used in combination with oral glucocorticoid therapy to induce remission, however, with a higher risk of relapse than when using rituximab or cyclophosphamide. For maintenance of remission, a tailored regimen of rituximab infusion was equivalent to a fixed regimen, with fewer perfusions. Belimumab, a human IgG1(Equation is included in full-text article.)monoclonal antibody against B-lymphocyte stimulator, did not decrease the relapse rate when added to azathioprine and glucocorticoids. Avacopan, a complement C5a receptor inhibitor, was effective in replacing high-dose glucocorticoids in achieving complete remission of vasculitis. SUMMARY Significant advances have been made in the treatment strategy to both induce remission and maintain remission in patients with ANCA-associated vasculitis. The choice should take into consideration efficacy, cost-effectiveness, safety profile, ease of use, and possibility of individual tailoring of treatment.
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41
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Mescia F, Egan AC, Cheema K, Sivasothy P, Jayne DRW. Eosinophilic granulomatosis with polyangiitis present and future. Rheumatology (Oxford) 2021; 60:iii24-iii27. [PMID: 34137880 DOI: 10.1093/rheumatology/keab033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/08/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Federica Mescia
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Vasculitis and Lupus Unit, Department of Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Allyson C Egan
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Vasculitis and Lupus Unit, Department of Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Kim Cheema
- Cummings School of Medicine, University of Calgary, Alberta, Canada
| | - Pasupathy Sivasothy
- Vasculitis and Lupus Unit, Department of Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Vasculitis and Lupus Unit, Department of Medicine, Addenbrooke's Hospital, Cambridge, UK
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42
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Egan AC, Peters J, Jolly E, Flint S, Sivasothy P, Jayne DRW. A critical beat in eosinophilic granulomatosis with polyangiitis. Rheumatology (Oxford) 2021; 60:iii28-iii31. [PMID: 34137885 DOI: 10.1093/rheumatology/keab180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/17/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Allyson C Egan
- Department of Medicine, Vasculitis and Lupus Centre, Cambridge University Hospital, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, London, UK
| | - James Peters
- Department of Immunology and Inflammation, Centre of Inflammatory Disease, Imperial College London, London, UK
| | - Elaine Jolly
- Department of Medicine, Vasculitis and Lupus Centre, Cambridge University Hospital, Cambridge, UK
| | - Shaun Flint
- Department of Medicine, Vasculitis and Lupus Centre, Cambridge University Hospital, Cambridge, UK
| | - Pasupathy Sivasothy
- Department of Medicine, Vasculitis and Lupus Centre, Cambridge University Hospital, Cambridge, UK
| | - David R W Jayne
- Department of Medicine, Vasculitis and Lupus Centre, Cambridge University Hospital, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, London, UK
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43
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Update on Maintenance Therapies for ANCA-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00176-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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44
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Monti S, Brandolino F, Milanesi A, Xoxi B, Delvino P, Montecucco C. Novel Therapies for ANCA-associated Vasculitis. Curr Rheumatol Rep 2021; 23:38. [PMID: 33909172 DOI: 10.1007/s11926-021-01010-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the most recent evidence on the treatment innovations and future prospective in the management of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). RECENT FINDINGS In AAV, a growing body of research is available on novel treatment options for remission induction and to clarify some uncertainties concerning the optimal use of available drugs. Efforts are being made to reduce the toxicity associated with high-dose, prolonged glucocorticoids (GC) regimens. Despite major advances in the prognosis of AAV, relapses are still common and the intensity and duration of remission treatment constitute a great challenge in the management of these chronic conditions. A paradigm shift in practice in the management of AAV is being supported by recent evidence suggesting the comparable efficacy and improved safety profile of schemes with a reduced dose of GC for the induction and maintenance of remission in patients with severe granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Moreover, recent appraisal of pathogenetic mechanisms, including complement activation pathways, has introduced the revolutionary concept of an alternative to GC, such as avacopan. Plasma exchange failed to prevent end-stage renal disease and mortality in patients with severe renal involvement or pulmonary haemorrhage according to a large multicentre randomised trial. Intensified immunosuppressive strategies for patients with life-threatening manifestations, including the combination of rituximab (RTX) with cyclophosphamide (CYC) have revealed promising preliminary data. New evidence for the use of alternative immunosuppressive agents (e.g. mycophenolate mofetil or abatacept) for the induction of remission in patients with non-severe disease is emerging. Several studies have been recently published, or are ongoing, to assess the optimal strategy and duration of maintenance of remission with the available treatment options (GC, azathioprine, and RTX). Preliminary evidence supports the superiority of a more prolonged course of maintenance treatment. The management of refractory or relapsing eosinophilic granulomatosis with polyangiitis (EGPA) has been improved by the recent demonstration of efficacy and safety of an interleukin-5 inhibitor, mepolizumab. Ongoing randomised studies will clarify the role of RTX in patients with severe manifestations of EGPA.
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Affiliation(s)
- Sara Monti
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy.
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy.
| | - Fabio Brandolino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Alessandra Milanesi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Blerina Xoxi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Paolo Delvino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
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45
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[Cortisone-free rheumatology-Vasculitides]. Z Rheumatol 2021; 80:314-321. [PMID: 33709164 DOI: 10.1007/s00393-021-00974-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 10/21/2022]
Abstract
Glucocorticoids (GC) still represent an essential pillar of treatment in the phase of remission induction of vasculitides, which are often organ or life-threatening; however, they entail a significant potential for side effects. In the phase of remission maintenance prednisolone should be reduced to 7.5 mg/day or less. Whether a discontinuation can alway be achieved for any form of vasculitis without increasing relapse rates, is unclear. By the use of biologics, e.g. tocilizumab in giant cell arteritis (GCA), a fast tapering and discontinuation of GC seems to be more easily achievable compared to using a GC monotherapy regimen. Avacopan could in the future be an efficient agent to spare GC in the phase of remission induction in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), e.g. granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Mepolizumab is a promising option to reduce the use of GC in eosinophilic granulomatosis with polyangiitis (EGPA).
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46
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Jayne D. Antineutrophil Cytoplasmic Antibody-associated Vasculitis Management 2020: Where Are We Now? J Rheumatol 2021; 48:479-481. [PMID: 33649076 DOI: 10.3899/jrheum.201351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- David Jayne
- D. Jayne, MD, FMedSci, Department of Medicine. University of Cambridge, Cambridge, UK.
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47
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Springer JM, Kalot MA, Husainat NM, Byram KW, Dua AB, James KE, Chang Lin Y, Turgunbaev M, Villa-Forte A, Abril A, Langford CA, Maz M, Chung SA, Mustafa RA. Eosinophilic Granulomatosis with Polyangiitis: A Systematic Review and Meta-Analysis of Test Accuracy and Benefits and Harms of Common Treatments. ACR Open Rheumatol 2021; 3:101-110. [PMID: 33512787 PMCID: PMC7882521 DOI: 10.1002/acr2.11194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
Objective Eosinophilic granulomatosis with polyangiitis (EGPA) is part of a group of vasculitides commonly referred to as antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV), in addition to granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and renal‐limited vasculitis. Patients with EGPA characteristically have asthma and marked peripheral eosinophilia with only approximately 30% to 35% of patients being myeloperoxidase (MPO)‐ANCA positive, distinguishing it from other forms of AAV (1,2). The aim of this systematic review is to support the development of the American College of Rheumatology/Vasculitis Foundation guideline for the management of EGPA. Methods A systematic review was conducted of the literature for seven forms of primary systemic vasculitis (GPA, MPA, EGPA, polyarteritis nodosa, Kawasaki disease, giant cell arteritis, and Takayasu arteritis). The search was done for articles in English using Ovid Medline, PubMed, Embase, and the Cochrane Library. Articles were screened for suitability in addressing population/patients, intervention, comparator, and outcomes (PICO) questions, with studies presenting the highest level of evidence given preference. Two independent reviewers conducted a title/abstract screen and full‐text review for each eligible study. Results The initial search, conducted in August 2019, included 13 800 articles, of which 2596 full‐text articles were reviewed. There were 190 articles (addressing 34 PICO questions) reporting on the diagnosis and management of EGPA. Conclusion This comprehensive systematic review synthesizes and evaluates the accuracy of commonly used tests for EGPA as well as benefits and toxicities of different treatment options.
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Affiliation(s)
| | | | | | | | - Anisha B Dua
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | | | | | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
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48
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Canzian A, Venhoff N, Urban ML, Sartorelli S, Ruppert AM, Groh M, Girszyn N, Taillé C, Maurier F, Cottin V, de Moreuil C, Germain V, Samson M, Jachiet M, Denis L, Rieu V, Smets P, Pugnet G, Deroux A, Durel CA, Aouba A, Cathébras P, Deligny C, Faguer S, Gil H, Godeau B, Lifermann F, Phin-Huynh S, Ruivard M, Bonniaud P, Puéchal X, Kahn JE, Thiel J, Dagna L, Guillevin L, Vaglio A, Emmi G, Terrier B. Use of Biologics to Treat Relapsing and/or Refractory Eosinophilic Granulomatosis With Polyangiitis: Data From a European Collaborative Study. Arthritis Rheumatol 2021; 73:498-503. [PMID: 33001543 DOI: 10.1002/art.41534] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 09/08/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To describe the efficacy and safety of biologics for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA). METHODS A retrospective European collaborative study was conducted in patients with EGPA who received treatment with biologics for refractory and/or relapsing disease. RESULTS Among the 147 patients with EGPA included in the study, 63 received rituximab (RTX), 51 received mepolizumab (MEPO), and 33 received omalizumab (OMA). At the time of inclusion, the median Birmingham Vasculitis Activity Score (BVAS) was 8.5 (interquartile range [IQR] 5-13) in the RTX group, while the median BVAS in the OMA group was 2 (IQR 1-4.5) and the median BVAS in the MEPO group was 2 (IQR 1-5). In patients receiving RTX, the median BVAS declined both at 6 months (median 1, IQR 0-4.5) and at 12 months (median 0, IQR 0-2), and the frequency of remission, partial response, treatment failure, and stopping treatment due to adverse events was 49%, 24%, 24%, and 3%, respectively. For the treatment of glucocorticoid (GC)-dependent asthma, patients who received MEPO had a much better GC-sparing effect and overall response than did patients who received OMA. The frequency of remission, partial response, treatment failure, and stopping treatment due to adverse events was 15%, 33%, 48%, and 4%, respectively, in the OMA group and 78%, 10%, 8%, and 4%, respectively, in the MEPO group. Remission rates at 12 months were 76% and 82% among patients receiving MEPO at a doses of 100 mg and 300 mg, respectively. CONCLUSION These results suggest that RTX could be effective in treating relapses of EGPA vasculitis. MEPO is highly effective with a good safety profile in patients with GC-dependent asthma. Our data suggest that 100 mg MEPO monthly could be an acceptable dosage for first-line therapy in selected instances of EGPA, recognizing, however, that this has not been compared to the validated dosage of 300 mg monthly.
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Affiliation(s)
- Alice Canzian
- National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, AP-HP, Université Paris Descartes, Paris, France
| | - Nils Venhoff
- University Medical Center Freiburg and University of Freiburg, Freiburg, Germany
| | | | - Silvia Sartorelli
- IRCCS San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Matthieu Groh
- National Referral Center for Hypereosinophilic Syndrome (CEREO), Hôpital Foch, Suresnes, France
| | | | - Camille Taillé
- Hôpital Bichat, AP-HP, Nord-Université de Paris, Centre de Référence des Maladies Pulmonaires Rares, INSERM UMR 1152, Paris, France
| | | | | | | | | | - Maxime Samson
- Centre Hospitalier Universitaire (CHU) de Dijon Bourgogne, Dijon, France
| | | | | | | | | | | | - Alban Deroux
- CHU de Grenoble Alpes, Hôpital Michallon, Grenoble, France
| | | | | | | | | | | | - Helder Gil
- Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | | | | | | | - Marc Ruivard
- CHU de Gabriel-Montpied, Clermont-Ferrand, France
| | - Philippe Bonniaud
- Centre de Référence des Maladies Pulmonaires Rares, CHU de Dijon Bourgogne, Université de Bourgogne, INSERM 1231, Dijon, France
| | - Xavier Puéchal
- National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, AP-HP, Université Paris Descartes, Paris, France
| | | | - Jens Thiel
- University Medical Center Freiburg and University of Freiburg, Freiburg, Germany
| | - Lorenzo Dagna
- IRCCS San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Loïc Guillevin
- National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, AP-HP, Université Paris Descartes, Paris, France
| | - Augusto Vaglio
- Azienda Ospedaliero Universitaria Meyer and University of Florence, Florence, Italy
| | | | - Benjamin Terrier
- National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, AP-HP, Université Paris Descartes, Paris, France
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Akiyama M, Kaneko Y, Takeuchi T. Rituximab for the treatment of eosinophilic granulomatosis with polyangiitis: A systematic literature review. Autoimmun Rev 2020; 20:102737. [PMID: 33340770 DOI: 10.1016/j.autrev.2020.102737] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We investigated the effectiveness of rituximab (an anti-CD20 monoclonal antibody) in patients with eosinophilic granulomatosis with polyangiitis (EGPA). METHODS We performed a systematic literature review from the inception dates until July 20, 2020 for articles reporting rituximab administration to treat EGPA. RESULTS We identified a total of 171 patients; most of the patients had refractory or relapsing disease, whereas 14 patients were newly diagnosed with EGPA. Rituximab was used for induction therapy in all patients and administered as four infusions of 375 mg/m2/week, or two infusions of 1000 mg, given 2 weeks apart. The observation period was 6-36 months after rituximab initiation. The remission rates (defined as a Birmingham Vasculitis Activity Score of 0 along with low dose glucocorticoid) were 36 to 100%. Anti-neutrophil cytoplasmic antibody (ANCA)-positive patients tended to respond better to rituximab than ANCA-negative patients. All studies reported the successful reduction of glucocorticoid dose after rituximab treatment. The median glucocorticoid dose at rituximab initiation was 12.5-60 mg/day, which was successfully reduced to 0-8.5 mg/day after rituximab treatment. Scheduled rituximab maintenance treatment significantly reduced the relapse rates as compared to rituximab administered on demand. No new safety signal was reported. CONCLUSION Rituximab effectively induced and sustained remission and reduced glucocorticoid dose in patients with newly diagnosed or relapsing and refractory EGPA; it also showed potentially greater benefit in ANCA-positive patients than in ANCA-negative patients.
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Affiliation(s)
- Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan.
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
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50
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Mendel A, Ennis D, Go E, Bakowsky V, Baldwin C, Benseler SM, Cabral DA, Carette S, Clements-Baker M, Clifford AH, Cohen Tervaert JW, Cox G, Dehghan N, Dipchand C, Dhindsa N, Famorca L, Fifi-Mah A, Garner S, Girard LP, Lessard C, Liang P, Noone D, Makhzoum JP, Milman N, Pineau CA, Reich HN, Rhéaume M, Robinson DB, Rumsey DG, Towheed TE, Trudeau J, Twilt M, Yacyshyn E, Yeung RSM, Barra LB, Khalidi N, Pagnoux C. CanVasc Consensus Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitis: 2020 Update. J Rheumatol 2020; 48:555-566. [PMID: 32934123 DOI: 10.3899/jrheum.200721] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE In 2015, the Canadian Vasculitis Research Network (CanVasc) created recommendations for the management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) in Canada. The current update aims to revise existing recommendations and create additional recommendations, as needed, based on a review of new available evidence. METHODS A needs assessment survey of CanVasc members informed questions for an updated systematic literature review (publications spanning May 2014 to September 2019) using Medline, Embase, and Cochrane. New and revised recommendations were developed and categorized according to the level of evidence and strength of each recommendation. The CanVasc working group used a 2-step modified Delphi procedure to reach > 80% consensus on the inclusion, wording, and grading of each new and revised recommendation. RESULTS Eleven new and 16 revised recommendations were created and 12 original (2015) recommendations were retained. New and revised recommendations are discussed in detail within this document. Five original recommendations were removed, of which 4 were incorporated into the explanatory text. The supplementary material for practical use was revised to reflect the updated recommendations. CONCLUSION The 2020 updated recommendations provide rheumatologists, nephrologists, and other specialists caring for patients with AAV in Canada with new management guidance, based on current evidence and consensus from Canadian experts.
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Affiliation(s)
- Arielle Mendel
- A. Mendel, MD, MSc, C.A. Pineau, MD, Division of Rheumatology, Lupus and Vasculitis Clinic, McGill University, Montréal, Québec;
| | - Daniel Ennis
- D. Ennis, MD, C. Baldwin, MD, N. Dehghan, MD, N. Dhindsa, MD, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia
| | - Ellen Go
- E. Go, MD, R.S. Yeung, MD, PhD, Division of Rheumatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Volodko Bakowsky
- V. Bakowsky, MD, Division of Rheumatology, QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia
| | - Corisande Baldwin
- D. Ennis, MD, C. Baldwin, MD, N. Dehghan, MD, N. Dhindsa, MD, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia
| | - Susanne M Benseler
- S.M. Benseler, MD, PhD, M. Twilt, MD, PhD, Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta
| | - David A Cabral
- D.A. Cabral, MBBS, Division of Pediatric Rheumatology, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia
| | - Simon Carette
- S. Carette, MD, MPhil, C. Pagnoux, MD, MSc, MPH, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario
| | - Marie Clements-Baker
- M. Clements-Baker, MD, T.E. Towheed, MD, MS, Division of Rheumatology, Queen's University, Kingston, Ontario
| | - Alison H Clifford
- A.H. Clifford, MD, J.W. Cohen Tervaert, MD, PhD, E. Yacyshyn, MD, Division of Rheumatology, University of Alberta, Edmonton, Alberta
| | - Jan Willem Cohen Tervaert
- A.H. Clifford, MD, J.W. Cohen Tervaert, MD, PhD, E. Yacyshyn, MD, Division of Rheumatology, University of Alberta, Edmonton, Alberta
| | - Gerard Cox
- G. Cox, MB, Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario
| | - Natasha Dehghan
- D. Ennis, MD, C. Baldwin, MD, N. Dehghan, MD, N. Dhindsa, MD, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia
| | - Christine Dipchand
- C. Dipchand, MD, MSc, Division of Nephrology, QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia
| | - Navjot Dhindsa
- D. Ennis, MD, C. Baldwin, MD, N. Dehghan, MD, N. Dhindsa, MD, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia
| | - Leilani Famorca
- L. Famorca, MD, S. Garner, MD, MSc, N. Khalidi, MD, Division of Rheumatology, McMaster University, Hamilton, Ontario
| | - Aurore Fifi-Mah
- A. Fifi-Mah, MD, Division of Rheumatology, University of Calgary, Calgary, Alberta
| | - Stephanie Garner
- L. Famorca, MD, S. Garner, MD, MSc, N. Khalidi, MD, Division of Rheumatology, McMaster University, Hamilton, Ontario
| | - Louis-Philippe Girard
- L.P. Girard, MD, MSc, Division of Nephrology, University of Calgary, Calgary, Alberta
| | - Clode Lessard
- C. Lessard, MD, Centre de Recherche Musculo-Squelettique, Trois-Rivières, Québec
| | - Patrick Liang
- P. Liang, MD, Division of Rheumatology, Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec
| | - Damien Noone
- D. Noone, MB, BCh, BAO, MSc, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Jean-Paul Makhzoum
- J.P. Makhzoum, MD, M. Rhéaume, MD, Division of Internal Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec
| | - Nataliya Milman
- N. Milman, MD, MSc, Division of Rheumatology, The Ottawa Hospital, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Christian A Pineau
- A. Mendel, MD, MSc, C.A. Pineau, MD, Division of Rheumatology, Lupus and Vasculitis Clinic, McGill University, Montréal, Québec
| | - Heather N Reich
- H.N. Reich, MD, PhD, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario
| | - Maxime Rhéaume
- J.P. Makhzoum, MD, M. Rhéaume, MD, Division of Internal Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec
| | - David B Robinson
- D.B. Robinson, MD, MSc, Section of Rheumatology, University of Manitoba, Winnipeg, Manitoba
| | - Dax G Rumsey
- D.G. Rumsey, MD, MSc, Division of Pediatric Rheumatology, University of Alberta, Edmonton, Alberta
| | - Tanveer E Towheed
- M. Clements-Baker, MD, T.E. Towheed, MD, MS, Division of Rheumatology, Queen's University, Kingston, Ontario
| | - Judith Trudeau
- J. Trudeau, MD, Division of Rheumatology, CISSS Chaudière-Appalaches, Université Laval, Québec City, Québec
| | - Marinka Twilt
- S.M. Benseler, MD, PhD, M. Twilt, MD, PhD, Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta
| | - Elaine Yacyshyn
- A.H. Clifford, MD, J.W. Cohen Tervaert, MD, PhD, E. Yacyshyn, MD, Division of Rheumatology, University of Alberta, Edmonton, Alberta
| | - Rae S M Yeung
- E. Go, MD, R.S. Yeung, MD, PhD, Division of Rheumatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Lillian B Barra
- L.B. Barra, MD, Division of Rheumatology, Department of Medicine, Western University, London, Ontario, Canada
| | - Nader Khalidi
- L. Famorca, MD, S. Garner, MD, MSc, N. Khalidi, MD, Division of Rheumatology, McMaster University, Hamilton, Ontario
| | - Christian Pagnoux
- S. Carette, MD, MPhil, C. Pagnoux, MD, MSc, MPH, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario
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