Rituximab versus azathioprine for maintenance in ANCA-associated vasculitis
Loïc Guillevin, Christian Pagnoux, Alexandre Karras, Chahera Khouatra, Olivier Aumaître, Pascal Cohen, François Maurier, Olivier Decaux, Jacques Ninet, Pierre Gobert, Thomas Quémeneur, Claire Blanchard-Delaunay, Pascal Godmer, Xavier Puéchal, Pierre-Louis Carron, Pierre-Yves Hatron, Nicolas Limal, Mohamed Hamidou, Maize Ducret, Eric Daugas, Thomas Papo, Bernard Bonnotte, Alfred Mahr, Philippe Ravaud, Luc Mouthon, French Vasculitis Study Group, Denis Bagnères, Edouard Begon, Anne-Bérangère Beucher, Frédérique Bocquentin, Ali Boumallassa, Matthias Büchler, Juliette Chabrol, Isabelle Delacroix, Xavier Delbrel, Aurélien Delluc, Hélène Desmurs-Clavel, Marc Fabre, Marie Frimat, Martine Gayraud, Guillaume Gondran, Bruno Graffin, Claire Grange, Frédéric Grassin, Isabelle Guichard, Catherine Hanrotel-Saliou, Abdeljallil Koreichi, Xavier Kyndt, Laure Lahaxe, David Launay, Marie Lino, Isabelle Marie, Roderick Meckenstock, Myriam Niel-Duriez, Yann Ollivier, Elisa Pasqualoni, Serge Perrot, Vincent Poindron, Jacques Pourrat, Nolwenn Rabot, Alain Ramassamy, Virginie Rieu, Alexandre Seidowsky, Serge Selberras, Raphaële Seror, Florence Vende, Jean-François Viallard, Laurence Vrigneaud, Ursula Warzocha, Loïc Guillevin, Christian Pagnoux, Alexandre Karras, Chahera Khouatra, Olivier Aumaître, Pascal Cohen, François Maurier, Olivier Decaux, Jacques Ninet, Pierre Gobert, Thomas Quémeneur, Claire Blanchard-Delaunay, Pascal Godmer, Xavier Puéchal, Pierre-Louis Carron, Pierre-Yves Hatron, Nicolas Limal, Mohamed Hamidou, Maize Ducret, Eric Daugas, Thomas Papo, Bernard Bonnotte, Alfred Mahr, Philippe Ravaud, Luc Mouthon, French Vasculitis Study Group, Denis Bagnères, Edouard Begon, Anne-Bérangère Beucher, Frédérique Bocquentin, Ali Boumallassa, Matthias Büchler, Juliette Chabrol, Isabelle Delacroix, Xavier Delbrel, Aurélien Delluc, Hélène Desmurs-Clavel, Marc Fabre, Marie Frimat, Martine Gayraud, Guillaume Gondran, Bruno Graffin, Claire Grange, Frédéric Grassin, Isabelle Guichard, Catherine Hanrotel-Saliou, Abdeljallil Koreichi, Xavier Kyndt, Laure Lahaxe, David Launay, Marie Lino, Isabelle Marie, Roderick Meckenstock, Myriam Niel-Duriez, Yann Ollivier, Elisa Pasqualoni, Serge Perrot, Vincent Poindron, Jacques Pourrat, Nolwenn Rabot, Alain Ramassamy, Virginie Rieu, Alexandre Seidowsky, Serge Selberras, Raphaële Seror, Florence Vende, Jean-François Viallard, Laurence Vrigneaud, Ursula Warzocha
Abstract
Background: The combination of cyclophosphamide and glucocorticoids leads to remission in most patients with antineutrophil cytoplasm antibody (ANCA)-associated vasculitides. However, even when patients receive maintenance treatment with azathioprine or methotrexate, the relapse rate remains high. Rituximab may help to maintain remission.
Methods: Patients with newly diagnosed or relapsing granulomatosis with polyangiitis, microscopic polyangiitis, or renal-limited ANCA-associated vasculitis in complete remission after a cyclophosphamide-glucocorticoid regimen were randomly assigned to receive either 500 mg of rituximab on days 0 and 14 and at months 6, 12, and 18 after study entry or daily azathioprine until month 22. The primary end point at month 28 was the rate of major relapse (the reappearance of disease activity or worsening, with a Birmingham Vasculitis Activity Score >0, and involvement of one or more major organs, disease-related life-threatening events, or both).
Results: The 115 enrolled patients (87 with granulomatosis with polyangiitis, 23 with microscopic polyangiitis, and 5 with renal-limited ANCA-associated vasculitis) received azathioprine (58 patients) or rituximab (57 patients). At month 28, major relapse had occurred in 17 patients in the azathioprine group (29%) and in 3 patients in the rituximab group (5%) (hazard ratio for relapse, 6.61; 95% confidence interval, 1.56 to 27.96; P=0.002). The frequencies of severe adverse events were similar in the two groups. Twenty-five patients in each group (P=0.92) had severe adverse events; there were 44 events in the azathioprine group and 45 in the rituximab group. Eight patients in the azathioprine group and 11 in the rituximab group had severe infections, and cancer developed in 2 patients in the azathioprine group and 1 in the rituximab group. Two patients in the azathioprine group died (1 from sepsis and 1 from pancreatic cancer).
Conclusions: More patients with ANCA-associated vasculitides had sustained remission at month 28 with rituximab than with azathioprine. (Funded by the French Ministry of Health; MAINRITSAN ClinicalTrials.gov number, NCT00748644; EudraCT number, 2008-002846-51.).
Source: PubMed