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Balogh L, Oláh K, Sánta S, Majerhoffer N, Németh T. Novel and potential future therapeutic options in systemic autoimmune diseases. Front Immunol 2024; 15:1249500. [PMID: 38558805 PMCID: PMC10978744 DOI: 10.3389/fimmu.2024.1249500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/17/2024] [Indexed: 04/04/2024] Open
Abstract
Autoimmune inflammation is caused by the loss of tolerance to specific self-antigens and can result in organ-specific or systemic disorders. Systemic autoimmune diseases affect a significant portion of the population with an increasing rate of incidence, which means that is essential to have effective therapies to control these chronic disorders. Unfortunately, several patients with systemic autoimmune diseases do not respond at all or just partially respond to available conventional synthetic disease-modifying antirheumatic drugs and targeted therapies. However, during the past few years, some new medications have been approved and can be used in real-life clinical settings. Meanwhile, several new candidates appeared and can offer promising novel treatment options in the future. Here, we summarize the newly available medications and the most encouraging drug candidates in the treatment of systemic lupus erythematosus, rheumatoid arthritis, Sjögren's disease, systemic sclerosis, systemic vasculitis, and autoimmune myositis.
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Affiliation(s)
- Lili Balogh
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Katalin Oláh
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Soma Sánta
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Nóra Majerhoffer
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Tamás Németh
- Department of Physiology, Semmelweis University School of Medicine, Budapest, Hungary
- MTA-SE “Lendület” Translational Rheumatology Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Semmelweis University, Budapest, Hungary
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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Löffler C, Hellmich B. [Management of ANCA-associated vasculitides]. Inn Med (Heidelb) 2024; 65:93-106. [PMID: 38253699 DOI: 10.1007/s00108-023-01655-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 01/24/2024]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an autoimmune-mediated inflammation of small and medium-sized vessels that can affect virtually any organ system and bears the risk of irreversible organ damage. Without treatment the mortality rates are high, which necessitates rapid diagnosis and initiation of treatment. Histological confirmation, which is not feasible in all cases, should be strived for, especially to delineate differential diagnoses and vasculitis mimics. The new American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) classification criteria are primarily designed for study purposes and show limitations in the routine application. Globally, the recently updated EULAR recommendations represent the most up to date management guidelines. Therapeutically, rituximab and cyclophosphamide in combination with glucocorticoids remain the pillars of treatment in remission induction for severe organ-threatening and life-threatening diseases. For the first time, mepolizumab and avacopan represent approved treatment options for specific entities that make a significant contribution to steroid reduction. New attention has been paid to patient-reported outcomes, for which a disease-specific outcome questionnaire is now available.
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Affiliation(s)
- Christian Löffler
- Klinik für Innere Medizin, Rheumatologie, Pneumologie, Nephrologie und Diabetologie, medius Klinik Kirchheim, Eugenstr. 3, 73230, Kirchheim unter Teck, Deutschland.
- Vaskulitis-Referenzzentrum der Europäischen Union ERN-RITA, Lehrkrankenhaus der Eberhard Karls Universität Tübingen, Kirchheim unter Teck, Deutschland.
- Klinik für Nephrologie, Endokrinologie, Hypertensiologie und Rheumatologie, Universitätsmedizin Mannheim, Medizinische Fakultät der Universität Heidelberg, Mannheim, Deutschland.
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie, Pneumologie, Nephrologie und Diabetologie, medius Klinik Kirchheim, Eugenstr. 3, 73230, Kirchheim unter Teck, Deutschland
- Vaskulitis-Referenzzentrum der Europäischen Union ERN-RITA, Lehrkrankenhaus der Eberhard Karls Universität Tübingen, Kirchheim unter Teck, Deutschland
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Bettiol A, Urban ML, Padoan R, Groh M, Lopalco G, Egan A, Cottin V, Fraticelli P, Crimi C, Del Giacco S, Losappio L, Moi L, Cinetto F, Caminati M, Novikov P, Berti A, Cameli P, Cathébras P, Coppola A, Durel CA, Folci M, Gullo AL, Lombardi C, Monti S, Parronchi P, Rivera CM, Solans R, Vacca A, Espígol-Frigolé G, Guarnieri G, Bianchi FC, Marchi MR, Tcherakian C, Kahn JE, Iannone F, Venerito V, Desaintjean C, Moroncini G, Nolasco S, Costanzo GAML, Schroeder JW, Ribi C, Tesi M, Gelain E, Mattioli I, Bello F, Jayne D, Prisco D, Vaglio A, Emmi G. Benralizumab for eosinophilic granulomatosis with polyangiitis: a retrospective, multicentre, cohort study. Lancet Rheumatol 2023; 5:e707-e715. [PMID: 38251561 DOI: 10.1016/s2665-9913(23)00243-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/31/2023] [Accepted: 09/07/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Interleukin-5 (IL-5) inhibitors represent novel therapies for eosinophilic granulomatosis with polyangiitis (EGPA). This study assessed the effectiveness and safety of the IL-5 receptor inhibitor benralizumab in a European cohort of patients with EGPA. METHODS This retrospective cohort study included patients with EGPA from 28 European referral centres of the European EGPA Study Group across six countries (Italy, France, UK, Russia, Spain, and Switzerland) who received benralizumab as any line of treatment between Jan 1, 2019, and Sep 30, 2022. We assessed the rates of complete response, defined as no disease activity (Birmingham Vasculitis Activity Score [BVAS] of 0) and a prednisone dose of up to 4 mg/day, in contrast to partial response, defined as a BVAS of 0 and a prednisone dose greater than 4 mg/day. Active disease manifestations, pulmonary function, variation in glucocorticoid dose, and safety outcomes were also assessed over a 12-month follow-up. FINDINGS 121 patients with relapsing-refractory EGPA treated with benralizumab at the dose approved for eosinophilic asthma were included (64 [53%] women and 57 [47%] men; median age at the time of beginning benralizumab treatment 54·1 years [IQR 44·2-62·2]). Complete response was reported in 15 (12·4%, 95% CI 7·1-19·6) of 121 patients at month 3, 25 (28·7%, 19·5-39·4) of 87 patients at month 6, and 32 (46·4%, 34·3-58·8) of 69 patients at month 12; partial response was observed in an additional 43 (35·5%, 27·0-44·8) patients at month 3, 23 (26·4%, 17·6-37·0) at month 6, and 13 (18·8%, 10·4-30·1) at month 12. BVAS dropped from 3·0 (IQR 2·0-8·0) at baseline to 0·0 (0·0-2·0) at months 3 and 6, and to 0·0 (0·0-1·0) at month 12. The proportion of patients with systemic manifestations, active peripheral neurological disease, ear, nose, and throat involvement, and pulmonary involvement decreased, with an improvement in lung function tests. Six patients relapsed after having a complete response. The oral prednisone (or equivalent) dose decreased from 10·0 mg/day (5·0-12·5) at baseline to 5·0 mg/day (3·6-8·5) at month 3 (p<0·01), to 5·0 mg/day (2·5-6·3) at month 6, and to 2·5 mg/day (0·0-5·0) at month 12 (p<0·0001). 19 (16%) of 121 patients had adverse events and 16 (13%) discontinued benralizumab. INTERPRETATION These data suggest that benralizumab could be an effective treatment for EGPA in real-life clinical practice. Further clinical trials are required to confirm the efficacy of benralizumab in patients with a higher baseline disease activity. FUNDING None.
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Affiliation(s)
- Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Firenze, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Firenze, Florence, Italy
| | - Roberto Padoan
- Division of Rheumatology, Department of Medicine, University of Padova, Padova, Italy
| | - Matthieu Groh
- National Referral Center for Hypereosinophilic Syndromes, Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Giuseppe Lopalco
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Allyson Egan
- Trinity Health Kidney Centre, Tallaght University Hospital, Dublin, Ireland
| | - Vincent Cottin
- Reference Center for Rare Pulmonary Diseases (OrphaLung), Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France; UMR754, National Research Institute for Agriculture, Food and the Environment, University of Lyon, Lyon, France
| | | | - Claudia Crimi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy; Respiratory Medicine Unit, Azienda Ospedaliero Universitaria Policlinico "G Rodolico-San Marco", Catania, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Laura Losappio
- Unit of Allergy and Clinical Immunology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laura Moi
- Division of Immunology and Allergy, Department of Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Vaud, Switzerland
| | - Francesco Cinetto
- Department of Medicine, University of Padova, Padova, Italy; Rare Disease Referral Center, Internal Medicine 1, Ca' Foncello Hospital, Treviso, Italy
| | - Marco Caminati
- Asthma Centre and Allergy Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Pavel Novikov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alvise Berti
- Rheumatology Unit, Santa Chiara Hospital, APSS Trento and CISMED, University of Trento, Trento, Italy
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | | | - Angelo Coppola
- Division of Respiratory Medicine, Ospedale San Filippo Neri-ASL Roma 1, Rome, Italy; Saint Camillus International University of Health Sciences, Rome, Italy
| | - Cécile-Audrey Durel
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marco Folci
- Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | | | - Carlo Lombardi
- Departmental Unit of Allergology, Clinical Immunology and Pneumology, Fondazione Poliambulanza, Brescia, Italy
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Firenze, Florence, Italy
| | - Carlos Martinez Rivera
- Department of Pneumology, Hospital Universitari Germans Trias i Pujol de Badalona, Universitat Autònoma de Barcelona, IGTP, Barcelona, Spain
| | - Roser Solans
- Systemic Autoimmune Diseases Unit, Internal Medicine Department, Vall d'Hebron Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Angelo Vacca
- Department of Precision and Regenerative Medicine and Ionian Area, UOC Medicina Interna "Guido Baccelli", University of Bari Aldo Moro, Policlinico, Bari, Italy
| | - Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Gabriella Guarnieri
- Department of Pneumology, Hospital Cittadella ULSS6 Euganea, Cittadella, Italy
| | | | - Maria Rita Marchi
- Department of Pneumology, Hospital Cittadella ULSS6 Euganea, Cittadella, Italy
| | | | - Jean-Emmanuel Kahn
- National Referral Center for Hypereosinophilic Syndromes, Department of Internal Medicine, APHP, CHU Ambroise Paré, Boulogne-Billancourt, France
| | - Florenzo Iannone
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Vincenzo Venerito
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Charlene Desaintjean
- Reference Center for Rare Pulmonary Diseases (OrphaLung), Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Santi Nolasco
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy; Respiratory Medicine Unit, Azienda Ospedaliero Universitaria Policlinico "G Rodolico-San Marco", Catania, Italy
| | | | - Jan Walter Schroeder
- Unit of Allergy and Clinical Immunology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Camillo Ribi
- Division of Immunology and Allergy, Department of Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Vaud, Switzerland
| | - Michelangelo Tesi
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Elena Gelain
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Irene Mattioli
- Department of Experimental and Clinical Medicine, University of Firenze, Florence, Italy
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Firenze, Florence, Italy
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Firenze, Florence, Italy
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy; Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Florence, Italy; Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Melbourne, VIC, Australia.
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He JL, Liu XY, Zhang Y, Niu L, Li XL, Xie XY, Kang YT, Yang LQ, Cai ZY, Long H, Ye GF, Zou JX. Eosinophilic granulomatosis with polyangiitis, asthma as the first symptom, and subsequent Loeffler endocarditis: A case report. World J Clin Cases 2023; 11:6523-6530. [PMID: 37900222 PMCID: PMC10601009 DOI: 10.12998/wjcc.v11.i27.6523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/18/2023] [Accepted: 09/01/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is a rare form of anti-neutrophil cytoplasmic antibody-associated vasculitis characterized by asthma, vasculitis, and eosinophilia. CASE SUMMARY We report an atypical case of EGPA in a 20-year-old female patient. Unlike previously reported cases of EGPA, this patient's initial symptom was asthma associated with a respiratory infection. This was followed by Loeffler endocarditis and cardiac insufficiency. She received treatment with methylprednisolone sodium succinate, low molecular weight heparin, recombinant human brain natriuretic peptide, furosemide, cefoperazone sodium/sulbactam sodium, and acyclovir. Despite prophylactic anticoagulation, she developed a large right ventricular thrombus. EGPA diagnosis was confirmed based on ancillary test results and specialty consultations. Subsequent treatment included mycophenolate mofetil. Her overall condition improved significantly after treatment, as evidenced by decreased peripheral blood eosinophils and cardiac markers. She was discharged after 17 d. Her most recent follow-up showed normal peripheral blood eosinophil levels, restored cardiac function, and a reduced cardiac mural thrombus size. CONCLUSION This case illustrates the swift progression of EGPA and underscores the significance of early detection and immediate intervention to ensure a favorable prognosis.
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Affiliation(s)
- Jia-Ling He
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Xing-Yu Liu
- Department of Orthopedic Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Yi Zhang
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Li Niu
- Department of Internal Cardiovascular Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Xin-Lin Li
- Department of Medical Cosmetology, Beijing Puxiang Traditional Chinese Medicine Hospital, Beijing 100080, China
| | - Xing-Yu Xie
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Yang-Ting Kang
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Lan-Qing Yang
- College of Pediatrics, Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Zheng-Yang Cai
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Hui Long
- Department of Internal Cardiovascular Medicine, People’s Hospital of Baiyun District, Guiyang 550014, Guizhou Province, China
| | - Guang-Fei Ye
- Department of Orthopedic Surgery, Hospital of Guizhou Panjiang Coal Power Group Limited Liability Company, Liupanshui 553537, Guizhou Province, China
| | - Jun-Xin Zou
- Department of Imaging, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Watanabe R, Hashimoto M. Eosinophilic Granulomatosis with Polyangiitis: Latest Findings and Updated Treatment Recommendations. J Clin Med 2023; 12:5996. [PMID: 37762936 PMCID: PMC10532073 DOI: 10.3390/jcm12185996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) causes necrotizing vasculitis and eosinophil-rich granulomatous inflammation in small- to medium-sized vessels, resulting in multiple organ damage. EGPA is classified as an antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, with myeloperoxidase-ANCA detected in approximately one-third of the patients. Conventional treatment of EGPA relies on systemic glucocorticoids (GCs) in combination with cyclophosphamide when poor prognostic factors are present; however, the dilemma between disease control and drug-related adverse effects has long been a challenge. Recent studies have revealed that the genetic background, pathophysiology, and clinical manifestations differ between ANCA-positive and ANCA-negative patients; however, mepolizumab, an interleukin (IL)-5 inhibitor, is effective in both groups, suggesting that the IL-5-eosinophil axis is deeply involved in the pathogenesis of both ANCA-positive and ANCA-negative EGPA. This review summarizes the latest knowledge on the pathophysiology of EGPA and focuses on the roles of eosinophils and ANCA. We then introduce the current treatment recommendations and accumulated evidence for mepolizumab on EGPA. Based on current unmet clinical needs, we discuss potential future therapeutic strategies for EGPA.
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Affiliation(s)
- Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Samson M, Devilliers H, Thietart S, Charles P, Pagnoux C, Cohen P, Karras A, Mouthon L, Terrier B, Puéchal X, Guillevin L. Score to assess the probability of relapse in granulomatosis with polyangiitis and microscopic polyangiitis. RMD Open 2023; 9:rmdopen-2022-002953. [PMID: 36972927 PMCID: PMC10069598 DOI: 10.1136/rmdopen-2022-002953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/12/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE To develop a score assessing the probability of relapse in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). METHODS Long-term follow-up data from GPA and MPA patients included in five consecutive randomised controlled trials were pooled. Patient characteristics at diagnosis were entered into a competing-risks model, with relapse as the event of interest and death the competing event. Univariate and multivariate analyses were computed to identify variables associated with relapse and build a score, which was then validated in an independent cohort of GPA or MPA patients. RESULTS Data collected from 427 patients (203 GPA, 224 MPA) at diagnosis were included. Mean±SD follow-up was 80.6±51.3 months; 207 (48.5%) patients experienced ≥1 relapse. Relapse risk was associated with proteinase 3 (PR3) positivity (HR=1.81 (95% CI 1.28 to 2.57); p<0.001), age ≤75 years (HR=1.89 (95% CI 1.15 to 3.13); p=0.012) and estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m² (HR=1.67 (95% CI 1.18 to 2.33); p=0.004) at diagnosis. A score, the French Vasculitis Study Group Relapse Score (FRS), from 0 to 3 points was modelised: 1 point each for PR3-antineutrophil cytoplasmic antibody positivity, eGFR ≥30 mL/min/1.73 m² and age ≤75 years. In the validation cohort of 209 patients, the 5-year relapse risk was 8% for a FRS of 0, 30% for 1, 48% for 2 and 76% for 3. CONCLUSION The FRS can be used at diagnosis to assess the relapse risk in patients with GPA or MPA. Its value for tailoring the duration of maintenance therapy should be evaluated in future prospective trials.
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Affiliation(s)
- Maxime Samson
- Department of Internal Medicine and Clinical Immunology, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Hervé Devilliers
- INSERM, CIC 1432, Clinical Epidemiology Unit, University of Burgundy, Dijon, France
| | - Sara Thietart
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Pitié Salpêtrière, Paris, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Pascal Cohen
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Alexandre Karras
- Department of Nephrology, AP-HP, Hopital Europeen Georges Pompidou, Paris, France
- Universite Paris Descartes, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Loic Guillevin
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
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