Microscopic polyangiitis medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Microscopic polyangiitis}} | {{Microscopic polyangiitis}} | ||
{{CMG}} | {{CMG}} ; {{AE}}{{VKG}} | ||
==Overview== | ==Overview== | ||
Microscopic polyangiitis responds well to treatment with glucocorticoids such as prednisone together with | [[Microscopic polyangiitis]] responds well to treatment with [[glucocorticoids]] such as [[prednisone]] together with an [[immunosuppressant]] such as [[cyclophosphamide]]. The combination of these 2 drugs decreases the remission of [[Microscopic polyangiitis]] by about 90%. | ||
== Medical Therapy == | == Medical Therapy == | ||
* Pharmacologic medical therapies for Microscopic polyangiitis include glucocorticoids and immunosuppressant.<ref name="pmid25992801">{{cite journal| author=Greco A, De Virgilio A, Rizzo MI, Gallo A, Magliulo G, Fusconi M et al.| title=Microscopic polyangiitis: Advances in diagnostic and therapeutic approaches. | journal=Autoimmun Rev | year= 2015 | volume= 14 | issue= 9 | pages= 837-44 | pmid=25992801 | doi=10.1016/j.autrev.2015.05.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25992801 }}</ref> | * Pharmacologic medical therapies for [[Microscopic polyangiitis]] include [[glucocorticoids]] and [[immunosuppressant]].<ref name="pmid25992801">{{cite journal| author=Greco A, De Virgilio A, Rizzo MI, Gallo A, Magliulo G, Fusconi M et al.| title=Microscopic polyangiitis: Advances in diagnostic and therapeutic approaches. | journal=Autoimmun Rev | year= 2015 | volume= 14 | issue= 9 | pages= 837-44 | pmid=25992801 | doi=10.1016/j.autrev.2015.05.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25992801 }}</ref><ref name="pmid23615499">{{cite journal |vauthors=Walsh M, Casian A, Flossmann O, Westman K, Höglund P, Pusey C, Jayne DR |title=Long-term follow-up of patients with severe ANCA-associated vasculitis comparing plasma exchange to intravenous methylprednisolone treatment is unclear |journal=Kidney Int. |volume=84 |issue=2 |pages=397–402 |date=August 2013 |pmid=23615499 |doi=10.1038/ki.2013.131 |url=}}</ref> | ||
=== '''Corticosteroids:''' === | === '''Corticosteroids:''' === | ||
* In more aggressive forms of the disease prednisone is interchanged with methylprednisolone | * In more aggressive forms of the disease [[prednisone]] is interchanged with [[methylprednisolone]].<ref name="pmid20235186">{{cite journal |vauthors=Walsh M, Merkel PA, Mahr A, Jayne D |title=Effects of duration of glucocorticoid therapy on relapse rate in antineutrophil cytoplasmic antibody-associated vasculitis: A meta-analysis |journal=Arthritis Care Res (Hoboken) |volume=62 |issue=8 |pages=1166–73 |date=August 2010 |pmid=20235186 |pmc=2946200 |doi=10.1002/acr.20176 |url=}}</ref><ref name="pmid26031284">{{cite journal |vauthors=Hellmich B |title=[Treatment strategies for ANCA-associated vasculitides] |language=German |journal=Z Rheumatol |volume=74 |issue=5 |pages=388–97 |date=June 2015 |pmid=26031284 |doi=10.1007/s00393-014-1532-7 |url=}}</ref> | ||
* Both mild and severe forms of the disease are administered together with cyclophosphamide which is given in intravenous pulses every 2 weeks | * Both mild and severe forms of the disease are administered together with [[cyclophosphamide]] which is given in intravenous pulses every 2 weeks. | ||
* After the first 3 doses, cyclophosphamide is administered every 3 weeks | * After the first 3 doses, [[cyclophosphamide]] is administered every 3 weeks. | ||
* Cyclophosphamide can also be given orally at a dose of 2 mg/kg/day, however, more side effects are seen with the oral dose, such as neutropenia. | * [[Cyclophosphamide]] can also be given orally at a dose of 2 mg/kg/day, however, more side effects are seen with the oral dose, such as [[neutropenia]]. | ||
* The dose of prednisone that is given is 1 mg/kg/day for less aggressive forms of the disease | * The dose of [[prednisone]] that is given is 1 mg/kg/day for less aggressive forms of the disease. | ||
* If Microscopic polyangiitis is severe, plasmapheresis may also be given in conjunction with an immunosuppressant and glucocorticoid. | * If [[Microscopic polyangiitis]] is severe, [[plasmapheresis]] may also be given in conjunction with an [[immunosuppressant]] and [[glucocorticoid]]. | ||
* Plasmapheresis has been shown to have benefit in patients with pulmonary and renal involvement. | * [[Plasmapheresis]] has been shown to have benefit in patients with [[pulmonary]] and [[renal]] involvement. | ||
** Preferred regimen (1): [[Methylprednisolone]] 1g/kg 3 times a day. | |||
** Preferred regimen (2): [[Cyclophosphamide]] 15 mg/kg. | |||
=== '''Rituximab''' === | === '''Rituximab''' === | ||
* Induction therapy using rituximab and glucocorticoids in a recent study conducted by RITUXVAS compared rituximab and cyclophosphamide. | * Induction therapy using [[rituximab]] and [[glucocorticoids]] in a recent study conducted by RITUXVAS compared [[rituximab]] and [[cyclophosphamide]].<ref name="pmid18281850">{{cite journal |vauthors=Jayne D |title=Challenges in the management of microscopic polyangiitis: past, present and future |journal=Curr Opin Rheumatol |volume=20 |issue=1 |pages=3–9 |date=January 2008 |pmid=18281850 |doi=10.1097/BOR.0b013e3282f370d1 |url=}}</ref><ref name="pmid25805743">{{cite journal |vauthors=McGregor JG, Hogan SL, Kotzen ES, Poulton CJ, Hu Y, Negrete-Lopez R, Kidd JM, Katsanos SL, Bunch DO, Nachman PH, Falk RJ |title=Rituximab as an immunosuppressant in antineutrophil cytoplasmic antibody-associated vasculitis |journal=Nephrol. Dial. Transplant. |volume=30 Suppl 1 |issue= |pages=i123–31 |date=April 2015 |pmid=25805743 |pmc=4447867 |doi=10.1093/ndt/gfv076 |url=}}</ref> | ||
* The trial showed no superiority, in that both medications were effective at inducing remission. However, the safety and the long term use of rituximab needs to be further addressed. | * The trial showed no superiority, in that both medications were effective at inducing [[remission]]. However, the safety and the long term use of [[rituximab]] needs to be further addressed. | ||
== Maintenance Therapy == | == Maintenance Therapy == | ||
The maintenance therapy for Microscopic polyangiitis is with azathioprine, which is less toxic to that of cyclophosphamide. Azathioprine is administered for 18 months | * The maintenance therapy for [[Microscopic polyangiitis]] is with [[azathioprine]], which is less toxic to that of [[cyclophosphamide]]. [[Azathioprine]] is administered for 18 months. | ||
** Preferred regimen (1):[[Azathioprine]] 1 to 2 mg/kg/day. | |||
Other medications that may be used as maintenance are: | * Other medications that may be used as maintenance are: | ||
* | ** Preferred regimen (1): [[Mycophenolate]] mofetil up to 1g twice a day. | ||
* Methotrexate: 0.3 to 25 mg/kg/week | ** Preferred regimen (2): [[Methotrexate]]: 0.3 to 25 mg/kg/week. | ||
==References== | ==References== | ||
Latest revision as of 13:47, 30 April 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]
Overview
Microscopic polyangiitis responds well to treatment with glucocorticoids such as prednisone together with an immunosuppressant such as cyclophosphamide. The combination of these 2 drugs decreases the remission of Microscopic polyangiitis by about 90%.
Medical Therapy
- Pharmacologic medical therapies for Microscopic polyangiitis include glucocorticoids and immunosuppressant.[1][2]
Corticosteroids:
- In more aggressive forms of the disease prednisone is interchanged with methylprednisolone.[3][4]
- Both mild and severe forms of the disease are administered together with cyclophosphamide which is given in intravenous pulses every 2 weeks.
- After the first 3 doses, cyclophosphamide is administered every 3 weeks.
- Cyclophosphamide can also be given orally at a dose of 2 mg/kg/day, however, more side effects are seen with the oral dose, such as neutropenia.
- The dose of prednisone that is given is 1 mg/kg/day for less aggressive forms of the disease.
- If Microscopic polyangiitis is severe, plasmapheresis may also be given in conjunction with an immunosuppressant and glucocorticoid.
- Plasmapheresis has been shown to have benefit in patients with pulmonary and renal involvement.
- Preferred regimen (1): Methylprednisolone 1g/kg 3 times a day.
- Preferred regimen (2): Cyclophosphamide 15 mg/kg.
Rituximab
- Induction therapy using rituximab and glucocorticoids in a recent study conducted by RITUXVAS compared rituximab and cyclophosphamide.[5][6]
- The trial showed no superiority, in that both medications were effective at inducing remission. However, the safety and the long term use of rituximab needs to be further addressed.
Maintenance Therapy
- The maintenance therapy for Microscopic polyangiitis is with azathioprine, which is less toxic to that of cyclophosphamide. Azathioprine is administered for 18 months.
- Preferred regimen (1):Azathioprine 1 to 2 mg/kg/day.
- Other medications that may be used as maintenance are:
- Preferred regimen (1): Mycophenolate mofetil up to 1g twice a day.
- Preferred regimen (2): Methotrexate: 0.3 to 25 mg/kg/week.
References
- ↑ Greco A, De Virgilio A, Rizzo MI, Gallo A, Magliulo G, Fusconi M; et al. (2015). "Microscopic polyangiitis: Advances in diagnostic and therapeutic approaches". Autoimmun Rev. 14 (9): 837–44. doi:10.1016/j.autrev.2015.05.005. PMID 25992801.
- ↑ Walsh M, Casian A, Flossmann O, Westman K, Höglund P, Pusey C, Jayne DR (August 2013). "Long-term follow-up of patients with severe ANCA-associated vasculitis comparing plasma exchange to intravenous methylprednisolone treatment is unclear". Kidney Int. 84 (2): 397–402. doi:10.1038/ki.2013.131. PMID 23615499.
- ↑ Walsh M, Merkel PA, Mahr A, Jayne D (August 2010). "Effects of duration of glucocorticoid therapy on relapse rate in antineutrophil cytoplasmic antibody-associated vasculitis: A meta-analysis". Arthritis Care Res (Hoboken). 62 (8): 1166–73. doi:10.1002/acr.20176. PMC 2946200. PMID 20235186.
- ↑ Hellmich B (June 2015). "[Treatment strategies for ANCA-associated vasculitides]". Z Rheumatol (in German). 74 (5): 388–97. doi:10.1007/s00393-014-1532-7. PMID 26031284.
- ↑ Jayne D (January 2008). "Challenges in the management of microscopic polyangiitis: past, present and future". Curr Opin Rheumatol. 20 (1): 3–9. doi:10.1097/BOR.0b013e3282f370d1. PMID 18281850.
- ↑ McGregor JG, Hogan SL, Kotzen ES, Poulton CJ, Hu Y, Negrete-Lopez R, Kidd JM, Katsanos SL, Bunch DO, Nachman PH, Falk RJ (April 2015). "Rituximab as an immunosuppressant in antineutrophil cytoplasmic antibody-associated vasculitis". Nephrol. Dial. Transplant. 30 Suppl 1: i123–31. doi:10.1093/ndt/gfv076. PMC 4447867. PMID 25805743.