POS0247 GLUCOCORTICOID TAPERING STRATEGY FOR ANCA-ASSOCIATED VASCULITIS: ADDRESSING THE GAP BETWEEN RECOMMENDATIONS AND REAL-WORLD PRACTICE

Abstract

BackgroundAntineutrophil cytoplasmic antibody -associated vasculitis (AAV) is usually treated with combination of high-dose glucocorticoid (GC) and immunosuppressive agents, followed by tapering GC dose. Although the European League Against Rheumatism (EULAR) has specific recommendations for tapering the GC dose, clinicians often taper it slower than recommended due to concerns of potential disease relapse. However, such slower taper may prolong GC exposure for the patients, increasing the risk of adverse events, particularly infection.ObjectivesThe aims of our study were (1) to clarify GC dose tapering in the treatment of AAV in a real-world setting, in contrast to the EULAR recommendation of 2015 and (2) to compare the incidence of AAV relapse and severe infection between patients underdoing EULAR-recommended tapering and those undergoing slower tapering than the recommendation.MethodsIn this multicenter (25 sites in Japan), observational, retrospective study of AAV, 541 patients who had initial or severe relapse were enrolled between January 2017 and June 2020. Of these, 349 patients with microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) who entered in GC tapering phase after successful induction treatment were included. These patients were then grouped on the pace of GC tapering, defined as the GC dose at 12 weeks after treatment initiation: (1) EULAR group: 7.5-10 mg/day of GC, according to the EULAR recommendation of 2015, and (2) SLOWER group: >10 mg/day of GC. Their baseline characteristics and clinical outcomes were compared. Primary outcome was defined as relapse-free days from treatment initiation, whereas secondary outcome included the incidence of infectious events requiring hospitalization within 48 weeks from treatment initiation. Multivariable analysis was performed to assess the relationship between tapering pace and clinical outcomes.ResultsThere were 44 patients (12.6%) in the EULAR group and 290 (83.2%) in the SLOWER group. Regarding baseline characteristics, compared with the EULAR group, the SLOWER group had significantly higher serum C-reactive protein level (EULAR, 5.89 ± 6.89 mg/dL vs SLOWER, 7.56 ± 6.01 mg/dL; p = 0.03), as well as a trend toward higher Birmingham Vasculitis Activity Score (version 3) (EULAR, 11.80 ± 7.01 SLOWER, 13.93 ± 7.06; p = 0.08) We did not observe any significant differences in the frequency of relapses between the two groups (EULAR, 8/44, 18.2% vs SLOWER, 55/290, 19.0%; p = 0.63). Multivariable Cox proportional hazard analysis revealed no relationship GC dose at 12 weeks from treatment initiation and incidence of relapse. However, upon logistic regression analysis, the SLOWER group was found to have significant higher risk of a severe infectious event within 48 weeks from treatment initiation (p = 0.046; hazard ratio, 1.27; 95% confidence interval, 1.004 – 1.601).ConclusionOur finding indicates that clinicians tended to taper GC slower for patients with higher disease activity. However, slower GC taper was not found to reduce the frequency of relapse. In addition, slower GC taper was found to increase the risk of a severe infection. Hence, clinicians should pay attention not only relapsing but also late GC taper resulting in the risk of serious infection, especially in patients with higher disease activity of AAV.