Rituximab for remission induction in elderly patients with ANCA-associated vasculitis
Introduction
Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are systemic small vessel vasculitis and categorized as granulomatosis with polyangiitis (Wegener’s), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (Churg–Strauss syndrome), and renal-limited vasculitis. The routine use of cyclophosphamide dramatically changed the prognosis associated with AAV, transforming many of these previously fatal diseases into chronic illnesses [1]. However, the cost of remission induction with cyclophosphamide is substantial with 42% of patients experiencing treatment-related side effects [2] with older age and renal dysfunction being important predictors of treatment-related adverse effects [3], [4]. Strategies minimizing or eliminating use of cyclophosphamide for remission induction have been the subject of randomized vasculitis trials in the last decade. Rituximab, a chimeric mAb that binds to the CD20, was approved for remission induction in AAV in 2011 based on RAVE and RITUXVAS trials [5], [6]. The mean age of patients in the rituximab arm of RAVE trial was 54 years and the median age of patients in the RITUXVAS study was 68 years with a range of 56–75 years. The efficacy and safety of rituximab for remission induction for AAV in elderly patients has not been well studied. We report our experience with using remission induction for AAV in elderly patients defined as age greater than or equal to 60 years at a single university medical center.
Section snippets
Study population
Potential patients for this retrospective study were identified from a vasculitis clinic database for the study period 2005–2014. To be included in the study, individuals had to be 60 years or older at the time of rituximab infusion, have a clinical diagnosis of GPA or MPA and received rituximab for remission induction. This study protocol was approved by the Office of Human Subjects Research and Institutional Review Board.
Acquisition of clinical and laboratory data
Patient demographics, clinical features at the time of diagnosis or
Results
The baseline characteristics of the 31 patients who met the inclusion criteria for this study are presented in Table 1. The mean (SD) age at the time of rituximab infusion among the entire cohort was 71 (6) years (range: 60–83 years). Majority of patients (77%) were Caucasian and female gender (68%). Eighteen patients had a new diagnosis of AAV and the remainder had relapsing disease. Nineteen patients in the cohort had a diagnosis of GPA and 12 patients had a diagnosis of MPA. The mean (SD)
Discussion
This retrospective single center study demonstrates that rituximab is effective for remission induction in elderly patient with AAV. The data also demonstrates that infectious complications are common in this age group.
ANCA-associated vasculitis (AAV) are predominantly diseases of older patients with a peak age of 65–74 years [7]. Elderly patients with AAV are predominantly MPO–ANCA positive compared to PR3 ANCA. AAV in elderly [8], [9], [10], [11] frequently involves the kidney [12]. AAV
Reference (15)
- et al.
ANCA-associated glomerulonephritis in the very elderly
Kidney Int
(2011) - et al.
Antiproteinase 3- and antimyeloperoxidase-associated vasculitis
Kidney Int
(2000) - et al.
Epidemiology of ANCA-associated vasculitis
Rheum Dis Clin North Am
(2010) Update on the European Vasculitis Study Group trials
Curr Opin Rheumatol
(2001)- et al.
Wegener granulomatosis: an analysis of 158 patients
Ann Intern Med
(1992) - Little MA, Nightingale P, Verburgh CA, Hauser T, De Groot K, Savage C, et al. Early mortality in systemic vasculitis:...
- et al.
Long-term patient survival in ANCA-associated vasculitis
Ann Rheum Dis
(2011)