Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.

Treatment for ANCA-Associated Vasculitis: What Are the Experts Prescribing?

Cozmuta¹, Raluca, Merkel², Peter A., Fraenkel³, Liana

St. Vincent Medical Center, Bridgeport, CT
Boston University School of Medicine, Boston, MA
Yale University School of Medicine, Veterans Affairs Connecticut Healthcare Systems, New Haven, CT

Background/Purpose:

Data from randomized controlled trials suggest that cyclophosphamide (CTX) and rituximab (RTX) are equally effective at inducing remission in severe ANCA-associated vasculitis (AAV), and although the types of risks differ, the burden of adverse events appears to be comparable in the short-term. Therefore, until long-term studies are available, decision making depends primarily on expert opinion and/or extrapolation from use of these agents in other conditions. The objective of this study was to examine treatment choices among AAV experts.

Methods:

We invited experts (defined as physicians whose practices focus on vasculitis and physicians engaged in research in vasculitis) to complete a web-based survey. Treatment choices were elicited for 3 scenarios [1) newly-diagnosed severe AAV in a treatment-naïve patient without co-morbidities, 2) recurrent severe AAV in a patient without co-morbidities previously treated with oral CTX, 3) recurrent severe AAV in a patient without co-morbidities previously treated with IV CTX] for 4 patient profiles [22 year-old woman, 62 year-old women, 22 year-old man, 62 year-old man]. Differences between groups were examined using multinomial generalized estimating equation analysis.

Results:

The survey was successfully delivered to 145 experts; opened by 94 and completed by 50. 77% were male, 49% were rheumatologists, and 39% were nephrologists. 90% were attending physicians and 4% were trainees. 67% reported spending the majority of their time in clinical practice, 31% in clinical research and 2% in basic research. 71% worked in a university hospital setting. 24% were from the US and 61% were from Europe. Preferences for treatment of newly-diagnosed young women (52% with RTX) differed significantly (p<0.001) from those for older men (76% with CTX) and older women (74% with CTX) (see Table). Efficacy, toxicity and cost were all important reasons underling experts' choices for patients with newly diagnosed AAV. Uncertainty regarding the efficacy of azathioprine and RTX to maintain remission had much less influence (see Figure). 60% or more of respondents preferred RTX for recurrent disease regardless of patients' age or sex.

Table. Treatment Preferences for AAV

	Newly Diagnosed AAV: Treatment Naïve*				Recurrent AAV: Received PO CTX - on AZA			Recurrent AAV: Received IV CTX - on AZA
	PO CTX	IV CTX	RTX	No Preference	CTX	RTX	No Preference	CTX	RTX	No Preference
Young Woman	2%	30%	56%	12%	2%	92%	6%	5.9%	88.2%	5.9%
Older Woman	10%	64%	10%	16%	17.6%	70.6%	11.8%	19.6%	60.8%	19.6%
Young Man	2%	48%	36%	14%	4%	84%	12%	10%	78%	12%
Older Man	12%	64%	10%	14%	16%	72%	12%	18.4%	61.2%	20.4%
* Treatment preferences for a young woman differ significantly from those of an older woman and older man.

Conclusion:

Most vasculitis experts prefer to prescribe RTX for young women with newly-diagnosed AAV and for all patients with recurrent disease who have been previously treated with either oral or IV CTX. In contrast, IV CTX is the preferred treatment among most experts for older patients with new-onset disease. There appears to be less agreement regarding the preferred treatment for newly-diagnosed young men.

To cite this abstract, please use the following information:
Cozmuta, Raluca, Merkel, Peter A., Fraenkel, Liana; Treatment for ANCA-Associated Vasculitis: What Are the Experts Prescribing? [abstract]. Arthritis Rheum 2011;63 Suppl 10 :2367
DOI:

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