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BIG SURPRISE ... Azathioprine in Systemic Necrotizing Vasculitis?
June 10 2016 6:00 AM ET — via RheumReports
We all see patients with non-life-threatening necrotizing vasculitidies including eosinophilic granulomatosis (eGPA), microscopic polyangiitis (MPA) and polyarteritis nodosa (PAN). Many of these patients present with constitutional symptoms, skin lesions, arthralgias, etc, but do not have serious organ involvement.
Up until now, I usually start these patients on a steroid-sparing agent such as azathioprine without much clinical data to justify this practice. I typically try to taper treatment over a few years, but many patients end up on immunosuppression for a prolonged period of time.
Thursday morning at EULAR 2016, Puechal from France presented a very informative (and frankly, surprising to me!) multicentre, double-blind, randomized controlled trial to answer this question. They studied 95 patients with necrotizing vasculitis (eGPA, MPA, PAN) who did not meet the five factor score. All patients received glucocorticoid 1 mg/kg/d, gradually tapered over 12 months and were randomized to placebo or azathioprine 2 mg/kg/d.
At 24 months of follow-up, 52.2% of AZA patients and 51% of placebo patients were in remission (off prednisone) without subsequent relapse. Secondary endpoints including remission rates, and minor and major flare rates were comparable between groups. There were two deaths in the AZA group (CHF, sudden death) but none in the placebo group. The mean glucocorticoid dose was comparable between the two groups. In addition, the addition of AZA did not reduce rates of asthma flares in patients with eGPA.
Based on this data, there does not seem to be a compelling reason to add azathioprine to the treatment regimen of patients with eGPA, MPA or PAN who do not have life-threatening disease. It appears that azathioprine does not affect remission rates, relapse rates or cumulative prednisone doses.
I have to say that this data surprises me…. I’m not sure if I am ready to change my practice yet, but this data certainly provides food for thought.
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About the Author
Dr. Shahin Jamal
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.
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