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ANCA-associated vasculitis: beyond therapy with rituximab?
Following the success of Phase 3 randomised controlled trials of non-renal and renal vasculitis, therapy with rituximab has tremendously improved the outcomes of AAV patients. However, some patients are unable to taper their glucocorticoids during rituximab therapy while others appear to be refractory to therapy, particularly those with EGPA. Hence, what are other current or future approaches beyond rituximab?
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EULAR 2023 – Day 2 Report
Day 2 at the international EULAR Congress meeting is always bigger and busier. There were sessions on JIA therapies, crystal arthritis, novel drugs for SLE and Sjogren's, early RA and preclinical RA interventions, IgG4 disease, osteoporosis and the growth and application of artificial intelligence in medicine and rheumatology.
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JAMA: Prophylaxis for Pneumocystis Pneumonia - indications and Rx
- Immuncompromised and Immunodeficient
- Pts on Hi Dose Steroids
- ANCA–associated vasculitis
https://t.co/2VhLxc4VNo https://t.co/cXuY4Manrk
Links:
Dr. John Cush RheumNow ( View Tweet)
RT @drdavidliew : Tapering pred in RA - this just rings true from everyday clinic life.
Some patients just seem to hit a wall at PNL 2.5. Sometimes it’s GC withdrawal arthralgias/tertiary adrenal insufficiency, but often it’s genuine inflammation.
I still wonder why?
POS0050
Dr. John Cush RheumNow ( View Tweet)
#Top #EULAR learnings #SLE #recommendations 1 Limit #prednisone 2 use #biologics early if poor prognosis 3 #lupus #nephritis - treat early with #belimumab or #voclosporin and more Rx in #RCTs #gamechanger https://t.co/JHQHu91tud
Janet Pope Janetbirdope ( View Tweet)
Important from @cappelliMD @jhrheumatology irAE cohort on predictors of DMARD requirement in ICI-inflammatory arthritis, and persistent ICI-IA post-ICI cessation.
The better we can predict these patients, the more we can get the right therapy early
POS0951 #EULAR2023 @RheumNow https://t.co/YGTRl71505
David Liew drdavidliew ( View Tweet)
New 2023 @eular_org SLE recommendations
Key changes, in response to evidence:
- more caution re: steroids
- biologics earlier
- combo therapy (BEL or CNI/VCS) considered for lupus nephritis
#EULAR2023 @RheumNow https://t.co/J3Lp8owRyT
David Liew drdavidliew ( View Tweet)
#SLE #EULAR recommendations What is new - use LESS #glucocorticoids, aim for none or 5 mg/d or less, use #biologics early if needed to prevent damage, #lupus #nephritis consider less pulse dose if using, voclosporin vs Belimumab ? it depends @RheumNow #EULAR2023 https://t.co/Ylnnl3pHOK
Janet Pope Janetbirdope ( View Tweet)
Meds in #lupus at #EULAR2023 recs
- HCQ first line therapy. Target dose remains the same. Some discussion on monitoring levels if possible
- MAIN CHANGE - Glucocorticoids to be minimized (only use for bridging). Nephrologists more so in favor of steroid free remission @RheumNow https://t.co/d8WnUOgrwq
Bella Mehta bella_mehta ( View Tweet)
We would think that targeted therapies would have reduced GC use in RA.
Well, this is not really the case.
Comaprison of GC use in 1999-2008 vs. 2009-2018
52% of patients remain on GC for>3Mo after initiation & 1/3 still continues after 2 years!
@RheumNow #EULAR23 POS0309 https://t.co/dDkUJFlmEm
Aurelie Najm AurelieRheumo ( View Tweet)
#EULAR2023 #POS0222 Post-hoc Analyses of Phase 3 RCT in Rituximab-treated ANCA vasculitis patients only (65% of total) showed more patients met Remission rate & with lower GC Toxicity vs Pred Taper + RTX at 52 weeks, consistent with Trial Main Results @RheumNow https://t.co/BmiujbhQI9
Md Yuzaiful Md Yusof Yuz6Yusof ( View Tweet)
Initial use of glucocorticoids GC as bridging treatment in RA resulted in increase use of GC later, fewer DMARD changes later, van Ouwerkek L, Abst#OP220 #EULAR2023 @RheumNow https://t.co/IjxgQTZ8SE
Dr. Antoni Chan synovialjoints ( View Tweet)
Treatment of IIM, MTX or AZA or IVIG are 1st line (with steroids). #EULAR2023 https://t.co/TDKWxgrST0
Dr. John Cush RheumNow ( View Tweet)
What do we do with PMR patients with subclinical GCA seen on ultrasound?
Well, in these non-blinded cohorts the subclinical GCA pts got more pred.
Was it warranted? Hard to say. If we’re going to look for it, let’s try and figure out what it means
POS0712 #EULAR2023 @RheumNow https://t.co/KmCcE0Nsu9
David Liew drdavidliew ( View Tweet)
Rx of #lupus #SLE The most challenging seems to be longstanding & residual disease activity - damage accumulates over time - esp if #glucocorticoids are used. Consider only as bridging. How to treat #lupus #EULAR2023 Boumpas @RheumNow #ClinicalPearl @eular_org https://t.co/heBbcRAjxO
Janet Pope Janetbirdope ( View Tweet)
Tapering pred in RA - this just rings true from everyday clinic life.
Some patients just seem to hit a wall at PNL 2.5. Sometimes it’s GC withdrawal arthralgias/tertiary adrenal insufficiency, but often it’s genuine inflammation.
I still wonder why?
POS0050 #EULAR2023 @RheumNow https://t.co/JBh26VqPuM
David Liew drdavidliew ( View Tweet)
CareRA trial:
3 months addition of LEF vs. ETA in pts resistant to COBRA-Slim regimen (MTX 15 mg/w + step-down prednisone):
After 2 years, no difference in dis control but those who received ETA early were treated more frequently w/ csDMARD monotherapy #EULAR23 @RheumNow OP0129 https://t.co/YwSoZWi375
Aurelie Najm AurelieRheumo ( View Tweet)
#EULAR2023 #OP0046 With more effective therapies in #lupus, we should aim for bare minimum/cessation of steroid. A study using French database showed:
>12% were on =>5mg Pred/d, this associated with comorbidities & increased costs
14% on high dose Pred weren’t on HCQ
@RheumNow https://t.co/x99Jt9yf1g
Md Yuzaiful Md Yusof Yuz6Yusof ( View Tweet)
I swear it is muscle, Doctor!
GLORIA trial substudy
Pred 5 mg/day 2 years in RA pts >65yo:
Weight gain 1kg vs. PBO, no increase or redistribution of fat mass but augmentation in lean mass 💪
Probably explained by better disease control (although NS in study, small sample size)
Aurelie Najm AurelieRheumo ( View Tweet)
#EULAR2023 Abstr #OP0048 What happened if we taper steroid in #lupus patients who are Serologically Active Clinically Quiescent? A cohort study in Asia showed:
- Tapering was NOT associated with subsequent flare
- Tapering reduced damage in those on =>5mg/day
@RheumNow https://t.co/Q6GiaSCgV6
Md Yuzaiful Md Yusof Yuz6Yusof ( View Tweet)
