Plasma Exchange and Glucocorticoids in Severe ANCA-Associated Vasculitis
RCT (n=704) found plasma exchange did not reduce incidence of death or end-stage kidney disease (ESKD) whilst reduced-dose regimen (RDR) of glucocorticoids was non-inferior to standard-DR with respect to death or ESKD. Serious infections at 1 year were less common with RDR.
Source:
New England Journal of Medicine
SPS commentary:
According to an editorial, the similar outcomes in the two glucocorticoid groups are of particular interest because many treatment-related adverse events are driven by the dose and duration of glucocorticoid regimens. It notes that in the reduced-dose group, the dose was tapered more rapidly, although patients in both groups received glucocorticoids for a minimum of 52 weeks and received the same dose for the last 29 weeks of this treatment period. It adds that observational data are equivocal regarding the benefits of glucocorticoid therapy beyond 6 months. It suggests that the trial provides additional useful insights into induction therapy for ANCA-associated vasculitis and that reducing glucocorticoid dosing is beneficial, though newer agents that specifically target innate immune mechanisms may eventually replace glucocorticoids altogether. It highlights that the findings indicate plasma exchange should not be used in most patients with ANCA-associated vasculitis who have severe kidney dysfunction, but it plasma exchange may benefit carefully selected subgroups of patients, including patients with concomitant anti–glomerular basement membrane disease and perhaps those with rapidly progressive glomerulonephritis but minimal scarring. It is of the opinion that until a study specifically designed to evaluate efficacy in patients with pulmonary haemorrhage has been performed, plasma exchange should remain part of the induction regimen for patients with ANCA-induced pulmonary haemorrhage.