Meeting NewsPerspective

Vasculitis guidelines support first-line biologic therapies in certain patients

Sharon Chung

ATLANTA — Increased use of glucocorticoid-sparing agents is one of the key recommendations in a guideline document that covers seven vasculitis diseases, according to a speaker at ACR/ARP 2019.

“This is the first set of guidelines for the vasculitides from the ACR, and the first such partnership with the Vasculitis Foundation,” Sharon Chung, MD, an assistant professor of rheumatology at the University of California, San Francisco, said during a press conference. “They will offer some reassurance for practitioners who may not be experienced in caring for these diseases.”

The document will cover recommendations for seven different diseases that fall under the vasculitis umbrella, including giant cell arteritis (GCA), Takayasu’s syndrome (TAK), polyarteritis nodosa (PAN), Kawasaki disease, and three types of ANCA-associated vasculitides.

The recommendations will be presented in multiple documents and offer guidance for everything from diagnostic tests such as serology, imaging and biopsy, to remission induction and maintenance therapies, to managing refractory disease, to possible surgery.

“It has often not been clear what is the first medication you should reach for when treating these patients,” Chung said. “These recommendations should help with that decision-making.”

A key component of the guideline is its support for the use of biologic therapies for first-line treatment for certain patient populations, according to Chung. She suggested that this is “particularly exciting” for patients, because more biologics means less steroids. “Biologics can decrease the weight gain, mood swings and bone loss associated with steroids,” Chung said.

Specifically, there are conditional recommendations for glucocorticoid-sparing agents as first-line therapy for GCA and a conditional recommendation for reduced-dose glucocorticoids for granulomatosis with polyangiitis and microscopic polyangiitis.

Turning to diagnostics, there is a conditional recommendation to use vascular imaging to identify large-vessel involvement in newly diagnosed GCA.

“We also recommend appropriate use of lab testing for patients,” Chung said. “We want to emphasize that the whole patient should be examined.”

Chung said the panel is not strictly opposed to laboratory analysis, but clinicians are also encouraged to assess the symptoms, comorbidities and disease activity in each individual patient to inform decision making.

Looking beyond the clinic, the recommendations call for additional research and additional training in the vasculitides. “Everyone wants to know: “How long should my patient be treated with a particular medication,” Chung said. “Often, the answer is, ‘I don’t know,’ because those studies have not been done.”

An important point of consideration is that the ACR/Vasculitis Foundation guidelines contradict recommendations from other societies in certain areas. For example, the ACR/Vasculitis Foundation document recommends biopsy over ultrasound. “This is not because ultrasound is a bad test, but because most people are not trained in using this test,” Chung said. “We should train people in this test so they can use them appropriately.”

The documents are still undergoing review processes. Publication is expected by the spring of 2020. – by Rob Volansky

Reference:
Chung S. ANCA-associated vasculitis: How to apply the new ACR guideline. Presented at: American College of Rheumatology/Association of Rheumatology Professionals Annual Meeting; Nov. 9-13, 2019; Atlanta.

Disclosure: Chung reports no relevant financial disclosures.

Sharon Chung

ATLANTA — Increased use of glucocorticoid-sparing agents is one of the key recommendations in a guideline document that covers seven vasculitis diseases, according to a speaker at ACR/ARP 2019.

“This is the first set of guidelines for the vasculitides from the ACR, and the first such partnership with the Vasculitis Foundation,” Sharon Chung, MD, an assistant professor of rheumatology at the University of California, San Francisco, said during a press conference. “They will offer some reassurance for practitioners who may not be experienced in caring for these diseases.”

The document will cover recommendations for seven different diseases that fall under the vasculitis umbrella, including giant cell arteritis (GCA), Takayasu’s syndrome (TAK), polyarteritis nodosa (PAN), Kawasaki disease, and three types of ANCA-associated vasculitides.

The recommendations will be presented in multiple documents and offer guidance for everything from diagnostic tests such as serology, imaging and biopsy, to remission induction and maintenance therapies, to managing refractory disease, to possible surgery.

“It has often not been clear what is the first medication you should reach for when treating these patients,” Chung said. “These recommendations should help with that decision-making.”

A key component of the guideline is its support for the use of biologic therapies for first-line treatment for certain patient populations, according to Chung. She suggested that this is “particularly exciting” for patients, because more biologics means less steroids. “Biologics can decrease the weight gain, mood swings and bone loss associated with steroids,” Chung said.

Specifically, there are conditional recommendations for glucocorticoid-sparing agents as first-line therapy for GCA and a conditional recommendation for reduced-dose glucocorticoids for granulomatosis with polyangiitis and microscopic polyangiitis.

Turning to diagnostics, there is a conditional recommendation to use vascular imaging to identify large-vessel involvement in newly diagnosed GCA.

“We also recommend appropriate use of lab testing for patients,” Chung said. “We want to emphasize that the whole patient should be examined.”

Chung said the panel is not strictly opposed to laboratory analysis, but clinicians are also encouraged to assess the symptoms, comorbidities and disease activity in each individual patient to inform decision making.

Looking beyond the clinic, the recommendations call for additional research and additional training in the vasculitides. “Everyone wants to know: “How long should my patient be treated with a particular medication,” Chung said. “Often, the answer is, ‘I don’t know,’ because those studies have not been done.”

An important point of consideration is that the ACR/Vasculitis Foundation guidelines contradict recommendations from other societies in certain areas. For example, the ACR/Vasculitis Foundation document recommends biopsy over ultrasound. “This is not because ultrasound is a bad test, but because most people are not trained in using this test,” Chung said. “We should train people in this test so they can use them appropriately.”

The documents are still undergoing review processes. Publication is expected by the spring of 2020. – by Rob Volansky

Reference:
Chung S. ANCA-associated vasculitis: How to apply the new ACR guideline. Presented at: American College of Rheumatology/Association of Rheumatology Professionals Annual Meeting; Nov. 9-13, 2019; Atlanta.

Disclosure: Chung reports no relevant financial disclosures.

    Perspective

    Vasculitis is a potentially deadly disease. As a rheumatologist, I may just have 20 or 30 patients with it. When we treat these patients, we use medications that are very expensive and come with significant morbidity. Biologic therapies are important treatments for these diseases, but it has been difficult to get their use approved by insurance companies for this patient population. These recommendations should help with that. And in the clinic, you can now tell a patient who is potentially dying from one of these diseases that they have therapeutic options, and that there are recommended therapies to treat them.

    • ​Donald Thomas, MD
    • Associate professor of clinical medicine
      Walter Reed National Military Medical Center

    Disclosures: Thomas reports no relevant financial disclosures.

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