A post-hoc analysis of combined trial data suggests that extending azathioprine maintenance therapy beyond 18 months is not necessary for preventing relapses among patients with antineutrophil cytoplasmic autoantibody-associated vasculitis.

Leflunomide, a DMARD used in the treatment of rheumatoid arthritis, is noninferior to azathioprine for the prevention of kidney flares in people with lupus nephritis, Chinese researchers report.

Noemie Jourde-Chiche (Aix-Marseille Université, France) and co-authors report in the Annals of the Rheumatic Diseases that the 2-year relapse rate was 27.3% in 44 patients who were randomly assigned to taper and discontinue maintenance immunosuppressive therapy with azathioprine or mycophenolate mofetil over a 3-month period after 2‒3 years of treatment.

David Jayne: One of the questions that comes up is whether we should move back to using oral immunosuppressants, like methotrexate or azathioprine, as remission-maintenance drugs.

The study included 21 patients on immunosuppressive maintenance therapy regimens involving combinations of steroids, azathioprine, mycophenolate mofetil, and rituximab, who received two doses of the BNT162b2 vaccine between March and May 2021, with a third dose given a median 103 days after the second.

The likelihood of hospitalization or death was also significantly higher among the patients receiving azathioprine/6-mercaptopurine monotherapy (odds ratio [OR]=1.84), azathioprine/6-mercaptopurine plus a TNF inhibitor (OR=1.74), or JAK inhibitor monotherapy (OR=1.82), relative to those on TNF inhibitor monotherapy.

Upadacitinib is approved at a dose of 15 mg/day for the treatment of PsA, and is not recommended for use in combination with other JAK inhibitors, biologic DMARDs, or potent immunosuppressants such as azathioprine or cyclosporine.

The efficacy of avacopan for ANCA-associated vasculitis was shown in the phase 3 ADVOCATE trial , which compared remission rates with the C5a receptor inhibitor versus placebo when added to standard treatment with rituximab or cyclophosphamide followed by azathioprine. medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2021 Springer Healthcare Ltd, part of the Springer Nature Group

They also evaluated vaccine immunogenicity in people treated with Janus kinase inhibitors, biologics, or antimetabolites such as methotrexate and azathioprine, but were unable to draw conclusions because confidence intervals around the estimates “were wide and overlapped with estimates among participants not using these therapies.”

Peter Merkel_040620 The rate of remission at week 26 – defined as a Birmingham Vasculitis Activity Score (BVAS) of 0 and no glucocorticoid treatment within the past 4 weeks – was 72.3% for the 166 participants who were randomly assigned to receive avacopan 30 mg twice daily alongside prednisone placebo and standard treatment with rituximab or cyclophosphamide followed by azathioprine.

On the other hand, there were significantly fewer complete responses in the high- versus medium-dose group among patients receiving remission induction therapy with azathioprine.

However, 66% said they would withhold methotrexate or leflunomide and 52% would withhold glucocorticoids of 20 mg/day or higher for 2 weeks or less if a live vaccine was available; and higher proportions would withhold tumor necrosis factor (TNF) inhibitors (85%), anti-IL-17/23 biologics (82%), Janus kinase inhibitors (78%), belimumab (77%), non-TNF biologics (76%), and immunosuppressive drugs such as azathioprine (64%) for a period of 3 to 8 weeks.

Gartshteyn et al say that rates of immunosuppressant use – including methotrexate, azathioprine, and rituximab – “were not different in patients with mild versus severe disease” at the time of hospital admission.

Rona Smith talks about the findings from the RITAZAREM trial, showing that maintenance therapy with rituximab reduces relapse rates compared with azathioprine among patients with ANCA-associated vasculitis (2:09).

Patients with ANCA-associated vasculitis who receive maintenance therapy with rituximab are more likely to remain in remission than those given azathioprine, according to the results of the RITAZAREM trial.

Richard Furie_050620 Furie explained that all patients received standard treatment comprising induction therapy with high-dose corticosteroids plus either cyclophosphamide or mycophenolate mofetil, followed by maintenance therapy with low-dose corticosteroids plus azathioprine or mycophenolate mofetil.

She stopped MMF and started azathioprine 100 mg/day.

The RITAZAREM trial aims to compare the efficacy of rituximab versus azathioprine for the maintenance of remission in patients with antineutrophil cytoplasmic antibody-associated vasculitis. Sunday 10 November, 11:00–12:30

RITAZAREM involves 170 patients with antineutrophil cytoplasmic antibody- associated vasculitis and relapsing disease who on achieving remission at 4 months were randomly assigned to maintenance treatment with rituximab or azathioprine. Sunday 10 November: 11:00–12:30

The csDMARDs included methotrexate, sulfasalazine, hydroxychloroquine, azathioprine, and leflunomide.