Granulomatosis with polyangiitis medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Wegener's granulomatosis}} | {{Wegener's granulomatosis}} | ||
{{CMG}}{{APM}}{{AE}}{{KW}}{{CZ}}{{ADS}} | |||
{{CMG}}{{APM}}{{AE}}{{KW}}{{CZ}} | |||
==Overview== | ==Overview== | ||
In most cases, treatment consists of a combination of a glucocorticoid (a steroid) and a cytotoxic medicine. | In most cases, treatment consists of a combination of a glucocorticoid (a steroid) and a cytotoxic medicine. It includes [[Glucocorticoid|glucocorticoids]], [[cyclophosphamide]], [[Rituximab]], [[Methotrexate]], [[Azathioprine]] and when needed with [[plasmapheresis]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
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=== Initial treatment === | === Initial treatment === | ||
==== Immunosuppressants ==== | ==== 1. Immunosuppressants ==== | ||
====== Glucocorticoids ====== | ====== 1.1 Glucocorticoids ====== | ||
* Parenteral regimen (pulse therapy) | * Parenteral regimen (pulse therapy) | ||
**Preferred regimen (1):[[Methylprednisolone]] 7-15 mg/kg IV q24h for 3 days (maximum, 500-1000 mg/kg/day) | **Preferred regimen (1):[[Methylprednisolone]] 7-15 mg/kg IV q24h for 3 days (maximum, 500-1000 mg/kg/day) | ||
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**Preferred regimen (1): [[Prednisone]] 1 mg/kg/day PO from Day 1 (maximum, 60-80 mg/day) tapered over 14 days with maximum of 20 mg/day | **Preferred regimen (1): [[Prednisone]] 1 mg/kg/day PO from Day 1 (maximum, 60-80 mg/day) tapered over 14 days with maximum of 20 mg/day | ||
====== Cyclophosphamide ====== | ====== 1.2 Cyclophosphamide ====== | ||
* Oral regimen | * Oral regimen | ||
** Preferred regimen (1):[[Cyclophosphamide]] 1.5-2 mg/kg PO q24h for 3-6 months or till remission is achieved (Check CBC for [[Neutropenia]] and administer [[Mesna]] for [[hemorrhagic cystitis]]) | ** Preferred regimen (1):[[Cyclophosphamide]] 1.5-2 mg/kg PO q24h for 3-6 months or till remission is achieved (Check CBC for [[Neutropenia]] and administer [[Mesna]] for [[hemorrhagic cystitis]]) | ||
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* Patients using [[cyclophosphamide]] should also receive glucocorticoids. | * Patients using [[cyclophosphamide]] should also receive glucocorticoids. | ||
====== Rituximab ====== | ====== 1.3 Rituximab ====== | ||
* Parenteral regimen | * Parenteral regimen | ||
**Preferred regimen (1): [[Rituximab]] 375 mg/m<sup>2</sup> IV q1week for 4 doses | **Preferred regimen (1): [[Rituximab]] 375 mg/m<sup>2</sup> IV q1week for 4 doses | ||
**Alternative regimen (1): [[Rituximab]] 1g IV q2weekly for 2 doses | **Alternative regimen (1): [[Rituximab]] 1g IV q2weekly for 2 doses | ||
====== Methotrexate ====== | ====== 1.4 Methotrexate ====== | ||
* Parenteral regimen | * Parenteral regimen<ref name="pmid16052540">{{cite journal |vauthors=Specks U |title=Methotrexate for Wegener's granulomatosis: what is the evidence? |journal=Arthritis Rheum. |volume=52 |issue=8 |pages=2237–42 |date=August 2005 |pmid=16052540 |doi=10.1002/art.21146 |url=}}</ref> | ||
**Preferred regimen (1): [[Methotrexate]] 7.5 mg q1weekly | **Preferred regimen (1): [[Methotrexate]] 7.5 mg IM/SQ q1weekly till 1 year or remission. | ||
* Oral regimen | |||
** Preferred regimen (1): [[Methotrexate]] 7.5 mg PO q1weekly till 1 year or remission. | |||
* It is used in patients without any end organ damage and no life threatening disease.<ref name="pmid10943874">{{cite journal |vauthors=Langford CA, Talar-Williams C, Sneller MC |title=Use of methotrexate and glucocorticoids in the treatment of Wegener's granulomatosis. Long-term renal outcome in patients with glomerulonephritis |journal=Arthritis Rheum. |volume=43 |issue=8 |pages=1836–40 |date=August 2000 |pmid=10943874 |doi=10.1002/1529-0131(200008)43:8<1836::AID-ANR20>3.0.CO;2-R |url=}}</ref> | |||
* Relapse rate are higher with Methotrexate.<ref name="pmid16052573">{{cite journal |vauthors=De Groot K, Rasmussen N, Bacon PA, Tervaert JW, Feighery C, Gregorini G, Gross WL, Luqmani R, Jayne DR |title=Randomized trial of cyclophosphamide versus methotrexate for induction of remission in early systemic antineutrophil cytoplasmic antibody-associated vasculitis |journal=Arthritis Rheum. |volume=52 |issue=8 |pages=2461–9 |date=August 2005 |pmid=16052573 |doi=10.1002/art.21142 |url=}}</ref> | |||
* Patients using [[methotrexate]] should also receive glucocorticoids. | |||
====== 1.4 Azathioprine ====== | |||
* Oral regimen | |||
** Preferred regimen (1): [[Azathioprine]] 2 mg/kg/day PO for 6 months | |||
==== 2. Plasma exchange ==== | |||
* Indications | |||
** Renal dysfunction due to [[glomerulonephritis]] | |||
** Positive [[Anti-glomerular basement membrane antibody]] | |||
** [[Pulmonary hemorrhage]] | |||
* Plasma exchange accompanies the pharmacological treatment | |||
Some guidelines for which drug to choose.<ref name="Bosch" /> | Some guidelines for which drug to choose.<ref name="Bosch" /> | ||
* In localized disease, treatment with the antibiotic [[co-trimoxazole]] is recommended, with steroids in case of treatment failure.<ref name="pmid8637536">{{cite journal |author=Stegeman CA, Tervaert JW, de Jong PE, Kallenberg CG |title=Trimethoprim-sulfamethoxazole (co-trimoxazole) for the prevention of relapses of Wegener's granulomatosis. Dutch Co-Trimoxazole Wegener Study Group |journal=N. Engl. J. Med. |volume=335 |issue=1 |pages=16–20 |year=1996 |pmid=8637536 |doi= |url=http://content.nejm.org/cgi/content/abstract/335/1/16}}</ref> | * In localized disease, treatment with the antibiotic [[co-trimoxazole]] is recommended, with steroids in case of treatment failure.<ref name="pmid8637536">{{cite journal |author=Stegeman CA, Tervaert JW, de Jong PE, Kallenberg CG |title=Trimethoprim-sulfamethoxazole (co-trimoxazole) for the prevention of relapses of Wegener's granulomatosis. Dutch Co-Trimoxazole Wegener Study Group |journal=N. Engl. J. Med. |volume=335 |issue=1 |pages=16–20 |year=1996 |pmid=8637536 |doi= |url=http://content.nejm.org/cgi/content/abstract/335/1/16}}</ref> | ||
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* In [[pulmonary hemorrhage]], high doses of cyclophosphamide with pulsed [[methylprednisolone]] may be used, or alternatively CYC, steroids, and plasma exchange. | * In [[pulmonary hemorrhage]], high doses of cyclophosphamide with pulsed [[methylprednisolone]] may be used, or alternatively CYC, steroids, and plasma exchange. | ||
In severe disease not responsive to previously mentioned treatment, | In severe disease not responsive to previously mentioned treatment, [[mycophenolate mofetil]], 15-deoxyspergualin, [[anti-thymocyte globulin]], [[rituximab]] and [[infliximab]]; [[intravenous immunoglobulin]] (IVIG) and [[etanercept]].<ref name="Bosch" /> | ||
===Other medicines=== | ===Other medicines=== | ||
Latest revision as of 17:29, 11 April 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Ali Poyan Mehr, M.D. [2]Associate Editor(s)-in-Chief: Krzysztof Wierzbicki M.D. [3]Cafer Zorkun, M.D., Ph.D. [4]Amandeep Singh M.D.[5]
Overview
In most cases, treatment consists of a combination of a glucocorticoid (a steroid) and a cytotoxic medicine. It includes glucocorticoids, cyclophosphamide, Rituximab, Methotrexate, Azathioprine and when needed with plasmapheresis.
Medical Therapy
Before steroid treatment became available, mortality within one year was over 90%, with average survival being 5 months. Steroids prolonged average survival to 8 months. The introduction of cyclophosphamide (CYC) in the 1970s was a major breakthrough.[1][2]
Initial treatment
1. Immunosuppressants
1.1 Glucocorticoids
- Parenteral regimen (pulse therapy)
- Preferred regimen (1):Methylprednisolone 7-15 mg/kg IV q24h for 3 days (maximum, 500-1000 mg/kg/day)
- Oral regimen (follows parenteral pulse therapy)
- Preferred regimen (1): Prednisone 1 mg/kg/day PO from Day 1 (maximum, 60-80 mg/day) tapered over 14 days with maximum of 20 mg/day
1.2 Cyclophosphamide
- Oral regimen
- Preferred regimen (1):Cyclophosphamide 1.5-2 mg/kg PO q24h for 3-6 months or till remission is achieved (Check CBC for Neutropenia and administer Mesna for hemorrhagic cystitis)
- Parenteral regimen (pulse therapy)
- Preferred regimen (1): Cyclophosphamide 15 mg/kg IV q2weekly for 3 doses and then q3weekly for 3-6 months (Check CBC for Neutropenia and administer Mesna for hemorrhagic cystitis)
- Patients using cyclophosphamide should also receive glucocorticoids.
1.3 Rituximab
- Parenteral regimen
1.4 Methotrexate
- Parenteral regimen[3]
- Preferred regimen (1): Methotrexate 7.5 mg IM/SQ q1weekly till 1 year or remission.
- Oral regimen
- Preferred regimen (1): Methotrexate 7.5 mg PO q1weekly till 1 year or remission.
- It is used in patients without any end organ damage and no life threatening disease.[4]
- Relapse rate are higher with Methotrexate.[5]
- Patients using methotrexate should also receive glucocorticoids.
1.4 Azathioprine
- Oral regimen
- Preferred regimen (1): Azathioprine 2 mg/kg/day PO for 6 months
2. Plasma exchange
- Indications
- Renal dysfunction due to glomerulonephritis
- Positive Anti-glomerular basement membrane antibody
- Pulmonary hemorrhage
- Plasma exchange accompanies the pharmacological treatment
Some guidelines for which drug to choose.[1]
- In localized disease, treatment with the antibiotic co-trimoxazole is recommended, with steroids in case of treatment failure.[6]
- In generalized non-organ threatening disease, remission can be induced with methotrexate and steroids, where the steroid dose is reduced after a remission has been achieved and methotrexate used as maintenance.
- In case of organ-threatening disease, pulsed intravenous cyclophosphamide with steroids is recommended. Once remission has been achieved, azathioprine and steroids can be used to maintain remission.
- In severe renal vasculitis, the same regimen is used but with the addition of plasma exchange.
- In pulmonary hemorrhage, high doses of cyclophosphamide with pulsed methylprednisolone may be used, or alternatively CYC, steroids, and plasma exchange.
In severe disease not responsive to previously mentioned treatment, mycophenolate mofetil, 15-deoxyspergualin, anti-thymocyte globulin, rituximab and infliximab; intravenous immunoglobulin (IVIG) and etanercept.[1]
Other medicines
During the course of treating Wegener's granulomatosis, doctors often give their patients other medicines to prevent medicine-related side effects. These include
- Trimethoprim/sulfamethoxazole (also called bactrim or septra) is given three times a week to prevent Pneumocystis carinii infection (a lung infection)
- A medicine regimen is often given to prevent prednisone-related bone loss (osteoporosis)
- Folic acid or folinic acid (also called leucovorin) are often given to people taking methotrexate
References
- ↑ 1.0 1.1 1.2 Bosch X, Guilabert A, Espinosa G, Mirapeix E (2007). "Treatment of antineutrophil cytoplasmic antibody associated vasculitis: a systematic review". JAMA. 298 (6): 655–69. doi:10.1001/jama.298.6.655. PMID 17684188.
- ↑ Flossmann O, Berden A, de Groot K, Hagen C, Harper L, Heijl C, Höglund P, Jayne D, Luqmani R, Mahr A, Mukhtyar C, Pusey C, Rasmussen N, Stegeman C, Walsh M, Westman K (March 2011). "Long-term patient survival in ANCA-associated vasculitis". Ann. Rheum. Dis. 70 (3): 488–94. doi:10.1136/ard.2010.137778. PMID 21109517.
- ↑ Specks U (August 2005). "Methotrexate for Wegener's granulomatosis: what is the evidence?". Arthritis Rheum. 52 (8): 2237–42. doi:10.1002/art.21146. PMID 16052540.
- ↑ Langford CA, Talar-Williams C, Sneller MC (August 2000). "Use of methotrexate and glucocorticoids in the treatment of Wegener's granulomatosis. Long-term renal outcome in patients with glomerulonephritis". Arthritis Rheum. 43 (8): 1836–40. doi:10.1002/1529-0131(200008)43:8<1836::AID-ANR20>3.0.CO;2-R. PMID 10943874.
- ↑ De Groot K, Rasmussen N, Bacon PA, Tervaert JW, Feighery C, Gregorini G, Gross WL, Luqmani R, Jayne DR (August 2005). "Randomized trial of cyclophosphamide versus methotrexate for induction of remission in early systemic antineutrophil cytoplasmic antibody-associated vasculitis". Arthritis Rheum. 52 (8): 2461–9. doi:10.1002/art.21142. PMID 16052573.
- ↑ Stegeman CA, Tervaert JW, de Jong PE, Kallenberg CG (1996). "Trimethoprim-sulfamethoxazole (co-trimoxazole) for the prevention of relapses of Wegener's granulomatosis. Dutch Co-Trimoxazole Wegener Study Group". N. Engl. J. Med. 335 (1): 16–20. PMID 8637536.