medwireNews: Recurrent venous thromboembolism (VTE) is more common in people with granulomatosis with polyangiitis (GPA) than among individuals in the general population who had an unprovoked first event, US researchers report in Rheumatology Advances in Practice.
The team, led by Alana Nevares, from the University of Vermont in Burlington, reviewed medical records for 147 patients with GPA and a history of deep vein thrombosis or pulmonary embolism who attended a single vasculitis center between 2002 and 2016.
Overall, 84 of these individuals met the study inclusion criteria of a confirmed GPA diagnosis, at least two follow-up visits, and one or more VTE events including at least one episode in the 3 months before GPA diagnosis or thereafter.
The majority of these patients were White (97.6%) men (56.0%), with a median age of 56 years at GPA diagnosis and 57 years at the time of first VTE episode.
Over a median 2.4 years of follow-up, the incidence of a second VTE was 8.4 per 100 patient–years, peaking in the first 6 months after the index event at 31.0 events per 100 patient–years.
When compared with the overall and 6-month rates of recurrent VTE in the general population (4.9 and 11.1 events per 100 person–years, respectively) and among patients with cancer (9.6 and 22.1 events per 100 person–years), the team says their data highlight the “magnitude of this comorbidity in in GPA.”
The cumulative rate of recurrence at 3 months was 9.7%, rising to 13.8% and 15.1% at 6 and 12 months, respectively, and 27.1% after both 3 and 5 years.
Nevares and co-authors note that 89.3% of first VTE events occurred during active GPA disease but that this proportion fell to just 57.7% of second VTE episodes, and therefore suggest that “VTE in GPA is a recurrent comorbidity, not always [occurring] during active vasculitis.”
They also observe that five of the 26 recurrent VTE events occurred in patients with inferior vena cava filters and no anticoagulation, “raising the question of whether such events were directly related to [inferior vena cava] filters or not.”
After adjusting for age and sex, individuals with constitutional symptoms at the time of GPA diagnosis (hazard ratio [HR]=2.5) or at time of first VTE (HR=2.5) were significantly more likely than those without to experience further VTE episodes.
There was also a significantly greater rate of recurrence among people with renal involvement at time of index VTE episode (HR=3.4), as well as among those with upper extremity VTE (HR=4.8).
By contrast, there was no significant relationship between the likelihood of recurrent VTE and other characteristics, such as duration of GPA, duration of anticoagulation use, and skin or nervous system involvement.
Analysis of transient risk factors for VTE showed that patients were significantly more likely to have a central, peripherally inserted central, or midline catheter at time of first versus second VTE (15.4 vs 0.0%) but the researchers postulate that this may simply reflect the higher rate of underlying severe illness at the index event, as indicated by the significant difference in the median Birmingham Vasculitis Activity Score for Wegener’s Granulomatosis at the two time points (8.5 vs 4.0).
“VTE in GPA patients, rather than a single event occurring merely during clinically apparent active disease, may be a recurring process that requires longer surveillance and therapy, particularly in those with renal involvement and constitutional symptoms,” Nevares et al conclude.
“There is a great need for prospective studies that can further explore the pathophysiology of recurrent VTE and estimate the risks and benefits of prolonged anticoagulation therapy in this unique patient population.”
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Rheum Adv Pract 2022; doi:10.1093/rap/rkac058