306. Rituximab in ANCA vasculitis -Is frequent maintenance with rituximab required? Experience from a Tertiary centre
Creators: name: Sahana Baliga1
Publisher: name: Zenodo
Year: 2022
Subjects: Vasculitis
ANCA
Abstracts
Giant Cell Arthritis
MPA
GPA
EGPA
Takayasu
IgA vasculitis

description: <strong>Background:</strong> ANCA associated vasculitis is a systemic disease affecting small and medium sized vessels. Cyclophosphamide based regimens in combination with glucocorticoids have shown promising efficacy with the treatment of ANCA associated vasculitis (AAV). However the risk of infection, malignancy and infertility is known to be associated with cyclophosphamide. Rituximab has been licensed for use in ANCA vasculitis since 2011.In the RAVE trial, Rituximab was found to be non- inferior to cyclophosphamide plus glucocorticoids followed by azathioprine maintenance therapy. Many trials have studied the efficacy of different immunosuppressants in the maintenance of AAV following induction. In case of persistent disease activity despite induction with cyclophosphamide or rituximab relapses are common in the first 6 months. In MAINRITSAN 3 study, 500 mg of rituximab infused every 6 months for an additional 18 months after an initial 18-month maintenance regimen was effective in reducing relapses. Relapse occurred in 2 out of 50 patients (4%) in the rituximab group versus 12 out of 47 (26%) in the placebo group during the 28-month follow-up. Extended therapy with biannual rituximab infusions over 18 months was associated with a lower incidence of AAV relapse compared to standard maintenance therapy.Here we share a real-world experience of use of Rituximab therapy in ANCA vasculitis from a tertiary care centre. <strong>Objectives:</strong> To study the real -world experience of the use of Rituximab in ANCA vasculitis as an initial therapy or in cases of treatment failure <strong>Methods</strong>: This is a retrospective descriptive analysis of 14 patients with ANCA associated vasculitis from our institute from 2010 to 2020 who received Rituximab. We studied the case records of these patients and documented the clinical features at presentation, laboratory findings, ANCA status, treatment given as induction and maintenance therapy and during relapse. We assessed the clinical remission after treatment with Rituximab. Criteria for remission was BVAS (Birmingham Vasculitis Activity Score) =0. <strong>Results:</strong> Out of 14 patients studied, 7 were females and 7 were males. The Median age of the patients was 35 years and the median duration of follow up was 10.5 years. Fever (71%), malaise (71%), arthritis (85%), pulmonary (92%) and renal (78%) manifestations were most commonly seen in these patients. Subglottic stenosis was seen in 2 out of 14 (14%) of the patients and both were females. 4 out of 14 patients were given Rituximab as initial induction therapy, out of which 3 out of 4 (75%) patients achieved complete clinical remission ,1 out of 3 (33.3%) did not improve.2 of the 3 patients with complete remission had received only single induction therapy with rituximab (2gm) followed by an oral maintenance immunosuppressive therapy and the mean duration of clinical remission in these patients was 5 years. (Figure 1) Rituximab was introduced after the failure of initial induction therapy in 10 out of 14 patients, which included cyclophosphamide, azathioprine, mycophenolate mofetil and methotrexate. 7 out of 10 (70%) patients achieved remission ,1 out of 10 (10%) showed partial response and 2 out of 10(30%) did not show response. Out of the 7 patients who responded, maintenance dose was given in 5 out of 7 patients and 3 out of 5 of them received only single dose of rituximab maintenance therapy (Figure1). The mean duration of clinical remission in these 7 patients from the last dose of rituximab (followed by oral maintenance immune suppression) was 3 years. <strong>Conclusions:</strong> From this real world retrospective observation analysis rituximab was effective as initial induction therapy and in cases of relapse/treatment failure. Although it produced complete remission in 70% of these patients,single dose of Rituximab as maintenance therapy was adequate in 35% of them with remission lasting for few years on other immunosuppressive therapy. Rituximab when used as upfront induction agent ,it could be substituted with other immunosuppressants as maintenance agents after induction remission. In resource limited settings ,oral maintenance immunosuppression can be used after successful rituximab induction in severe disease activity or treatment failure or relapse cases.Extended rituximab maintenance therapy may be not be required in all patients. Vigilant close monitoring of disease activity would be absolutely essential . A larger study would be required to corroborate our findings. <strong>Disclosures:</strong> None