SAT0248 PATTERNS OF DRUG TREATMENT FOR MAINTENANCE PHASE OF ANCA-ASSOCIATED VASCULITIS (AAV) IN REAL WORLD PRACTICE IN EUROPE – PROLONGED GLUCOCORTICOID USE IS COMMON AND VARIOUS TREATMENT REGIMES ARE USED
Authors: P. Rutherford, D. Götte
Journal: Annals of the Rheumatic Diseases (2020)

Background: Maintenance therapy following remission induction in ANCA associated vasculitis (AAV) is required to prevent relapse but patients are also still at risk from long term organ damage. This can be due to disease activity and also adverse events from therapy in particular high dose and prolonged use of glucocorticoids (GC). Objectives: This retrospective study aimed to examine clinical outcomes and in particular the drug treatment used for maintenance in AAV patients managed in routine clinical practice in Europe. Methods: 1478 AAV patients (France, Germany, Italy, Spain and UK) managed by 493 physicians (37% Rheumatologists) who completed induction therapy for organ or life threatening AAV and initiated maintenance therapy between 2014-16 were studied. Data were collected at the time maintenance was determined to begin by the physician and then at 6, 12, 18 and 36 months. 49% had granulomatosis with polyangiitis,; mean age 54.2 years with 56% male. 49% had incident AAV and 51% were studied from a relapse. 70% received cyclophosphamide and GC and 30% received rituximab (RTX) and GC for remission induction therapy. Results: Definition of maintenance start from the time of incidence/relapse and initial maintenance therapy varied between incident patients (mean time 4.7 months, GCs 66%, Azathioprine 38%, RTX 19%, Cyclophosphamide 11%) and relapsed patients (mean time 6.5 months *, GCs 63%, Azathioprine 30% *, RTX 24% *, Cyclophosphamide 20% *, p&lt;0.05 vs incident). RTX use was notably higher in relapsing patients in Italy, Spain and UK compared to incident patients. Control of AAV activity varied over follow up and prolonged GC use was common even after 36 months including in RTX treated patients. Maintenance start 6 months 12 months 18 months 36 months Remission full/partial % 43 / 50 59 / 38 67 / 30 72 / 25 74 / 22 Receiving GC % 65 61 53 46 39 5mg or less 19 40 58 68 72 5-10mg 34 41 35 27 23 10-20 mg 25 16 6 4 4 More than 20mg 22 3 2 1 1 Receiving RTX % 21 21 19 17 14 RTX alone 10 10 10 11 8 RTX + GC 10 10 8 5 5 RTX + other + no GC 1 1 1 1 1 RTX maintenance schedules varied - 375mg/6 monthly 22%, 500mg/6 monthly 36%, 1000mg/6 monthly 31%, 375mg/12 monthly 1%, 500mg/12 monthly 4% and 100mg/12 monthly 3%. 32% had RTX initial regime adjustments on basis of B cell counts (44%), age (34%) or immunoglobulin levels (22%). Over 36 months 28% patients relapsed, 18% minor and 10% major (who then left follow up in this study). This led to greater GC use in the minor relapse patients at 36 months compared to those maintaining remission without relapse (48% vs 38%). Conclusion: Maintenance therapy regimes used in clinical practice in Europe are variable including on basis of incident vs relapsing disease yet full remission is often not maintained. Many patients remain on GCs for long periods placing the patients at higher risk of GC related adverse events and organ damage. Even minor relapse increases the prolonged use of GCs. The high burden of prolonged GC use in AAV should be more clearly recognized and new therapeutic approaches explored. Disclosure of Interests: Peter Rutherford Shareholder of: Vifor Pharma, Employee of: Vifor Pharma, Baxter Healthcare, Dieter Götte Shareholder of: Vifor Pharma, Employee of: Vifor Pharma