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Drugs

, Volume 66, Issue 9, pp 1209–1228 | Cite as

Pharmacological Therapy for Wegener’s Granulomatosis

Review Article

Abstract

Wegener’s granulomatosis (WG) is the most common pulmonary granulomatous vasculitis and was a uniformly fatal disease prior to the identification of efficacious pharmacological regimens. The pathogenesis of WG remains elusive but proteinase 3-specific anti-neutrophil cytoplasmic antibodies may be involved. Histologically, WG is defined by the triad of small vessel necrotising vasculitis, ‘geographic’ necrosis and granulomatous inflammation. Organ involvement characteristically includes the upper and lower respiratory tracts and kidney, but virtually any organ can be involved. The severity of the disease varies, ranging from asymptomatic disease to fulminant, fatal vasculitis. Similarly, the degree of organ involvement is highly variable; WG may be limited to a single organ (typically the lungs or upper respiratory tract), or may be systemic. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids, which induces complete remission in the majority of patients, is considered standard therapy. Since approximately 50% of patients experience a relapse following discontinuation of therapy, alternative regimens designed to maintain remissions after using cyclophosphamide and corticosteroids are usually necessary. This ‘induction maintenance’ approach to treatment has emerged as a central premise in planning therapy for patients with WG.

A number of trials have evaluated the efficacy of less toxic immunosuppressants (e.g. methotrexate, azathioprine, mycophenolate mofetil) and antibacterials (i.e. cotrimoxazole [trimethoprim/sulfamethoxazole]) for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remissions in certain sub-populations of patients. Given the efficacy of methotrexate (for early systemic WG) and cotrimoxazole (in WG limited solely to the upper airways) to induce remissions, and the relatively decreased associated morbidity compared with cyclophosphamide, these alternative regimens are preferred in appropriate patients. Similarly, therapeutic options to maintain disease remission that are less toxic than cyclophosphamide should be offered following induction of remission unless a specific contraindication exists. By following this premise, the development of cyclophosphamide-induced morbidities (e.g. haemorrhagic cystitis, uroepithelial cancers and prolonged myelosuppression) may be minimised. Recent investigation has focussed on other immunomodulatory agents (tumour necrosis factor-α inhibitors [infliximab and etanercept] and anti-CD20 antibodies [rituximab]) for treating patients with WG. However, the current data are conflicting and difficult to interpret. As a result, these newer agents cannot be recommended for routine use until vigorous clinical study confirms their efficacy.

Keywords

Cyclophosphamide Infliximab Etanercept Birmingham Vasculitis Activity Score Rapidly Progressive Glomerulonephritis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

Dr White is supported in part by National Institutes of Health Grant K08-HL70990 and by an Association of Subspecialty Professors — CHEST Foundation T. Franklin Williams Geriatrics Research Development Award. The authors have no conflict of interest to report.

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© Adis Data Information BV 2006

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical Medicine, Department of Internal MedicineUniversity of Michigan Medical CenterAnn ArborUSA
  2. 2.Department of Medicine, Division of PulmonaryThe David Geffen School of Medicine at UCLA, Critical Care Medicine and HospitalistsLos AngelesUSA

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