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Zeitschrift für Rheumatologie

, Volume 76, Issue 2, pp 133–142 | Cite as

Aktuelle Leitlinien zu ANCA-assoziierten Vaskulitiden

Gemeinsamkeiten und Unterschiede
Leitthema

Zusammenfassung

Ergebnisse zahlreicher prospektiver und teils auch randomisierter kontrollierter Studien haben in den vergangenen Jahren zu Änderungen etablierter Strategien zur Therapie der mit antineutrophilen zytoplasmatischen Antikörpern (ANCA) assoziierten Vaskulitiden (AAV) geführt. Seit 2014 haben insgesamt 4 Fachgesellschaften bzw. Studiengruppen die neuen Daten systematisch analysiert und basierend auf ihrer Auswertung evidenzbasierte Empfehlungen zum Management der AAV formuliert. Diese Empfehlungen enthalten Informationen zu Diagnose, Induktions- bzw. Erhaltungstherapie, supportiven Therapiemaßnahmen sowie zum Monitoring von Krankheitsaktivität und Folgeschäden. In dieser Übersicht vergleichen wir die jüngst publizierten Empfehlungen der Deutschen Gesellschaft für Rheumatologie (DGRh), der European League against Rheumatism (EULAR)/European Renal Association (ERA), der British Society of Rheumatology (BSR) und des Canadian Vasculitis Research Network (CanVasc). Die vergleichende Analyse ergibt zu zahlreichen Themen ein hohes Maß an Übereinstimmung, aber zeigt auch in vielen Punkten in Details abweichende und vereinzelt auch deutlich diskrepante Vorschläge zur Diagnose und Therapie der AAV. Abweichende Empfehlungen bestehen v. a. bei Themen mit geringer Evidenz aus klinischen Studien. Zudem resultieren einige Differenzen auch als Folge unterschiedlicher Bewertungen der publizierten Daten oder der Besonderheiten des jeweiligen nationalen Gesundheitssystems.

Schlüsselwörter

Therapie Diagnose Empfehlungen Evidenz Studien 

Current guidelines on ANCA-associated vasculitides

Common features and differences

Abstract

The results of a number of prospective randomized controlled clinical trials have led to changes in established strategies for the treatment of antineutrophil cytoplasmic antibody (ANCA) associated vasculitides (AAV) in recent years. Since 2014, a total of 4 scientific societies and study groups have systematically reviewed the new data and have formulated evidence-based recommendations for the management of AAV based on the analysis. These recommendations contain information on diagnosis, treatment (induction and maintenance), supportive care and monitoring of disease activity and resulting damage. This review compares the recently published recommendations of the German Society of Rheumatology (Deutschen Gesellschaft für Rheumatologie, DGRh), the European League Against Rheumatism (EULAR)/European Renal Association (ERA), the British Society of Rheumatology (BSR) and the Canadian Vasculitis Research Network (CanVasc). The comparative analysis reveals a high level of agreement on numerous topics but also shows some minor and even a few major differences in the respective recommended approach to diagnosis and treatment of AAV. Divergent recommendations predominantly exist in areas with little scientific evidence from clinical studies. Furthermore, some differences result from different interpretation of existing data or are influenced by characteristic features of the respective national healthcare system.

Keywords

Treatment Diagnosis Recommendations Evidence Studies 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

B. Hellmich war als Koautor an der Erstellung der EULAR-Recommendations 2009 und 2016 und der DGRh-Leitlinie zum Management der AAV beteiligt und hat folgende Zuwendungen von der Industrie erhalten: Vortragshonorare – Abbvie, BMS, Celgen, Novartis, Orgentec, Pfizer, Roche; Honorare für Beratungsleistungen – BMS, Nippon-Kayaku, GSK, BMS, Roche.

Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Berden AE, Ferrario F, Hagen EC et al (2010) Histopathologic classification of ANCA-associated glomerulonephritis. J Am Soc Nephrol 21:1628–1636CrossRefPubMedGoogle Scholar
  2. 2.
    Cartin-Ceba R, Diaz-Caballero L, Al-Qadi MO et al (2016) Diffuse alveolar hemorrhage secondary to antineutrophil cytoplasmic antibody-associated vasculitis: predictors of respiratory failure and clinical outcomes. Arthritis Rheumatol 68:1467–1476CrossRefPubMedGoogle Scholar
  3. 3.
    Cartin-Ceba R, Golbin JM, Keogh KA et al (2012) Rituximab for remission induction and maintenance in refractory granulomatosis with polyangiitis (Wegener’s): ten-year experience at a single center. Arthritis Rheum 64:3770–3778. doi: 10.1002/art.34584 CrossRefPubMedGoogle Scholar
  4. 4.
    Charles P, Bienvenu B, Bonnotte B et al (2013) Rituximab: recommendations of the french vasculitis study group (FVSG) for induction and maintenance treatments of adult, antineutrophil cytoplasm antibody-associated necrotizing vasculitides. Presse Med 42:1317–1330CrossRefPubMedGoogle Scholar
  5. 5.
    Csernok E, Damoiseaux J, Rasmussen N et al (2016) Evaluation of automated multi-parametric indirect immunofluorescence assays to detect anti-neutrophil cytoplasmic antibodies (ANCA) in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Autoimmun Rev 15:736–741CrossRefPubMedGoogle Scholar
  6. 6.
    Damoiseaux J, Csernok E, Rasmussen N et al (2016) Detection of antineutrophil cytoplasmic antibodies (ANCAs): a multicentre European Vasculitis Study Group (EUVAS) evaluation of the value of indirect immunofluorescence (IIF) versus antigen-specific immunoassays. Ann Rheum Dis. doi: 10.1136/annrheumdis-2016-209507 PubMedGoogle Scholar
  7. 7.
    Finkielman JD, Merkel PA, Schroeder D et al (2007) Antiproteinase 3 antineutrophil cytoplasmic antibodies and disease activity in Wegener granulomatosis. Ann Intern Med 147:611–619CrossRefPubMedGoogle Scholar
  8. 8.
    Guerry MJ, Brogan P, Bruce IN et al (2012) Recommendations for the use of rituximab in anti-neutrophil cytoplasm antibody-associated vasculitis. Rheumatology (Oxford) 51:634–643CrossRefGoogle Scholar
  9. 9.
    Guillevin L, Pagnoux C, Karras A et al (2014) Rituximab versus azathioprine for maintenance in ANCA-associated vasculitis. N Engl J Med 371:1771–1780. doi: 10.1056/NEJMoa1404231 CrossRefPubMedGoogle Scholar
  10. 10.
    Han F, Liu G, Zhang X et al (2011) Effects of mycophenolate mofetil combined with corticosteroids for induction therapy of microscopic polyangiitis. Am J Nephrol 33:185–192CrossRefPubMedGoogle Scholar
  11. 11.
    Harper L, Morgan MD, Walsh M et al (2012) Pulse versus daily oral cyclophosphamide for induction of remission in ANCA-associated vasculitis: long-term follow-up. Ann Rheum Dis 71(200429):955–960. doi: 10.1136/annrheumdis-2011-200477 CrossRefPubMedGoogle Scholar
  12. 12.
    Hellmich B, Flossmann O, Gross WL et al (2007) EULAR recommendations for conducting clinical studies and/or clinical trials in systemic vasculitis: focus on anti-neutrophil cytoplasm antibody-associated vasculitis. Ann Rheum Dis 66:605–617CrossRefPubMedGoogle Scholar
  13. 13.
    Herlyn K, Buckert F, Gross WL et al (2014) Doubled prevalence rates of ANCA-associated vasculitides and giant cell arteritis between 1994 and 2006 in northern Germany. Rheumatology (Oxford) 53:882–889CrossRefGoogle Scholar
  14. 14.
    Herlyn K, Gross WL, Reinhold-Keller E (2008) Longitudinal effects of structured patient education programs for vasculitis patients. Z Rheumatol 67:206–210CrossRefPubMedGoogle Scholar
  15. 15.
    Hiemstra TF, Walsh M, Mahr A et al (2010) Mycophenolate mofetil vs azathioprine for remission maintenance in antineutrophil cytoplasmic antibody-associated vasculitis: a randomized controlled trial. JAMA 304:2381–2388CrossRefPubMedGoogle Scholar
  16. 16.
    Holle JU, Gross WL, Latza U et al (2011) Improved outcome in 445 patients with Wegener’s granulomatosis in a German vasculitis center over four decades. Arthritis Rheum 63:257–266CrossRefPubMedGoogle Scholar
  17. 17.
    Hu W, Liu C, Xie H et al (2008) Mycophenolate mofetil versus cyclophosphamide for inducing remission of ANCA vasculitis with moderate renal involvement. Nephrol Dial Transplant 23:1307–1312CrossRefPubMedGoogle Scholar
  18. 18.
    Jayne D, Chapel H, Adu D et al (2000) Intravenous immunoglobulin for ANCA-associated systemic vasculitis with persistent disease activity. QJM 93:433–439CrossRefPubMedGoogle Scholar
  19. 19.
    Jennette JC, Falk RJ, Bacon PA et al (2013) 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum 65:1–11CrossRefPubMedGoogle Scholar
  20. 20.
    Lapraik C, Watts R, Bacon P et al (2007) BSR and BHPR guidelines for the management of adults with ANCA associated vasculitis. Rheumatology (Oxford) 46:1615–1616CrossRefGoogle Scholar
  21. 21.
    Luxton G, Langham R (2008) The CARI guidelines. ANCA serology in the diagnosis and management of ANCA-associated renal vasculitis. Nephrology (Carlton) 13(Suppl 2):S17–S23CrossRefGoogle Scholar
  22. 22.
    Martin-Garrido I, Carmona EM, Specks U et al (2013) Pneumocystis pneumonia in patients treated with rituximab. Chest 144:258–265CrossRefPubMedGoogle Scholar
  23. 23.
    Mcgeoch L, Twilt M, Famorca L et al (2016) CanVasc recommendations for the management of antineutrophil cytoplasm antibody-associated vasculitides. J Rheumatol 43:97–120CrossRefPubMedGoogle Scholar
  24. 24.
    Menahem S, Hiremagalur B, Mudge D et al (2008) The CARI guidelines. Induction and maintenance therapy in ANCA-associated systemic vasculitis. Nephrology (Carlton) 13(Suppl 2):S24–S36CrossRefGoogle Scholar
  25. 25.
    Merkel PA, Lo GH, Holbrook JT et al (2005) Brief communication: high incidence of venous thrombotic events among patients with Wegener granulomatosis: the Wegener’s Clinical Occurrence of Thrombosis (WeCLOT) Study. Ann Intern Med 142:620–626CrossRefPubMedGoogle Scholar
  26. 26.
    Metzler C, Fink C, Lamprecht P et al (2004) Maintenance of remission with leflunomide in Wegener’s granulomatosis. Rheumatology 63:339–340Google Scholar
  27. 27.
    Miloslavsky EM, Specks U, Merkel F et al (2013) Efficacy of glucocorticoids to treat limited flares in ANCA-associated vasculitis. Arthritis Rheum 65:S315–S316CrossRefGoogle Scholar
  28. 28.
    Miloslavsky EM, Specks U, Merkel PA et al (2014) Rituximab for the treatment of relapses in antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheumatol 66:3151–3159. doi: 10.1002/art.38788 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Moosig F, Aries PM, De Groot K et al (2014) B‑cell targeted therapy in patients with granulomatosis with polyangiitis and microscopic polyangiitis. Dtsch Med Wochenschr 139:2248–2253CrossRefPubMedGoogle Scholar
  30. 30.
    Moosig F, Gross WL, Herrmann K et al (2011) Targeting interleukin-5 in refractory and relapsing Churg-Strauss syndrome. Ann Intern Med 155:341–343CrossRefPubMedGoogle Scholar
  31. 31.
    Mukhtyar C, Guillevin L, Cid MC et al (2009) EULAR recommendations for the management of primary small and medium vessel vasculitis. Ann Rheum Dis 68:310–317CrossRefPubMedGoogle Scholar
  32. 32.
    Ntatsaki E, Carruthers D, Chakravarty K et al (2014) BSR and BHPR guideline for the management of adults with ANCA-associated vasculitis. Rheumatology (Oxford) 53:2306–2309. doi: 10.1093/rheumatology/ket2445 CrossRefGoogle Scholar
  33. 33.
    Ribi C, Cohen P, Pagnoux C et al (2008) Treatment of Churg-Strauss syndrome without poor-prognosis factors: a multicenter, prospective, randomized, open-label study of seventy-two patients. Arthritis Rheum 58:586–594CrossRefPubMedGoogle Scholar
  34. 34.
    Roberts DM, Jones RB, Smith RM et al (2014) Rituximab-associated hypogammaglobulinemia: Incidence, predictors and outcomes in patients with multi-system autoimmune disease. J Autoimmun 31:00173–00175Google Scholar
  35. 35.
    Savige J, Dimech W, Fritzler M et al (2003) Addendum to the International Consensus Statement on testing and reporting of antineutrophil cytoplasmic antibodies. Quality control guidelines, comments, and recommendations for testing in other autoimmune diseases. Am J Clin Pathol 120:312–318CrossRefPubMedGoogle Scholar
  36. 36.
    Schirmer JH, Aries P, De Groot K et al (2016) S1 Leitlinie Diagnostik und Therapie der ANCA-assoziierten Vaskulitiden. Z Rheumatol (eingereicht)Google Scholar
  37. 37.
    Japanese Circulation Society (2011) Guideline for management of vasculitis syndrome (JCS 2008). Japanese Circulation Society. Circ J 75:474–503CrossRefGoogle Scholar
  38. 38.
    Specks U, Merkel PA, Seo P et al (2013) Efficacy of remission-induction regimens for ANCA-associated vasculitis. N Engl J Med 369:417–427CrossRefPubMedGoogle Scholar
  39. 39.
    Stegeman CA, Tervaert JW, De Jong PE et al (1996) Trimethoprim-sulfamethoxazole (co-trimoxazole) for the prevention of relapses of Wegener’s granulomatosis. Dutch Co-Trimoxazole Wegener Study Group. N Engl J Med 335:16–20CrossRefPubMedGoogle Scholar
  40. 40.
    Stone JH, Merkel PA, Spiera R et al (2010) Rituximab versus cyclophosphamide for ANCA-associated vasculitis. N Engl J Med 363:221–232CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Suppiah R, Flossman O, Mukhtyar C et al (2011) Measurement of damage in systemic vasculitis: a comparison of the Vasculitis Damage Index with the Combined Damage Assessment Index. Ann Rheum Dis 70:80–85CrossRefPubMedGoogle Scholar
  42. 42.
    Suppiah R, Judge A, Batra R et al (2011) A model to predict cardiovascular events in patients with newly diagnosed Wegener’s granulomatosis and microscopic polyangiitis. Arthritis Care Res 63:588–596CrossRefGoogle Scholar
  43. 43.
    Suppiah R, Mukhtyar C, Flossmann O et al (2011) A cross-sectional study of the Birmingham Vasculitis Activity Score version 3 in systemic vasculitis. Rheumatology (Oxford) 50:899–905CrossRefGoogle Scholar
  44. 44.
    Tadema H, Heeringa P, Kallenberg CG (2011) Bacterial infections in Wegener’s granulomatosis: mechanisms potentially involved in autoimmune pathogenesis. Curr Opin Rheumatol 23:366–371CrossRefPubMedGoogle Scholar
  45. 45.
    Tomasson G, Grayson PC, Mahr AD et al (2012) Value of ANCA measurements during remission to predict a relapse of ANCA-associated vasculitis – a meta-analysis. Rheumatology (Oxford) 51:100–109. doi: 10.1093/rheumatology/ker1280 CrossRefGoogle Scholar
  46. 46.
    Walsh M, Casian A, Flossmann O et al (2013) Long-term follow-up of patients with severe ANCA-associated vasculitis comparing plasma exchange to intravenous methylprednisolone treatment is unclear. Kidney Int 84:397–402. doi: 10.1038/ki.2013.1131 CrossRefPubMedGoogle Scholar
  47. 47.
    Walsh M, Merkel PA, Mahr A et al (2010) Effects of duration of glucocorticoid therapy on relapse rate in antineutrophil cytoplasmic antibody-associated vasculitis: A meta-analysis. Arthritis Care Res 62:1166–1173CrossRefGoogle Scholar
  48. 48.
    Yates M, Watts RA, Bajema IM et al (2016) EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis. doi: 10.1136/annrheumdis-2016-209133 Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  1. 1.Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Klinik KirchheimAkademisches Lehrkrankenhaus der Universität TübingenKirchheim u. TeckDeutschland

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