Effect of Treatment on Damage and Hospitalization in Elderly Patients with Microscopic Polyangiitis and Granulomatosis with Polyangiitis

Abstract

Objective.Age is a risk factor for organ damage, adverse events, and mortality in microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA). However, the relationship between treatment and damage, hospitalizations, and causes of death in elderly patients is largely unknown.Methods.Consecutive patients from Sweden, the United Kingdom, and the Czech Republic diagnosed between 1997 and 2013 were included. Inclusion criteria were a diagnosis of MPA or GPA and age 75 years or more at diagnosis. Treatment with cyclophosphamide (CYC), rituximab (RTX), and corticosteroids the first 3 months was registered. Outcomes up to 2 years from diagnosis included Vasculitis Damage Index (VDI), hospitalization, and cause of death.Results.Treatment data were available for 167 of 202 patients. At 2 years, 4% had no items of damage. There was a positive association between VDI score at 2 years and Birmingham Vasculitis Activity Score at onset, and a negative association with treatment using CYC or RTX. Intravenous methylprednisolone dose was associated with treatment-related damage. During the first year, 69% of patients were readmitted to hospital. Myeloperoxidase–antineutrophil cytoplasmic antibody positivity and lower creatinine levels decreased the odds of readmission. The most common cause of death was infection, and this was associated with cumulative oral prednisolone dose.Conclusion.Immunosuppressive treatment with CYC or RTX in elderly patients with MPA and GPA was associated with development of less permanent organ damage and was not associated with hospitalization. However, higher doses of corticosteroids during the first 3 months was associated with treatment-related damage and fatal infections.

CanVasc Consensus Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitis: 2020 Update

“…IV MP was associated with a nearly 3-fold higher risk of serious infection at 3 months, and a 6-fold higher risk of new-onset diabetes mellitus (8). Other studies also found IV MP to be independently associated with severe infections (10,11), and treatment-related damage (12).…”

Treatment Outcomes of Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitis in Patients Over Age 75 Years: A Meta-Analysis

“…As disease severity at presentation is known risk factor for permanent organ damage (29), this finding likely reflects the benefit of attenuated disease activity achieved with therapy. There was no increased rate of hospitalisation or length of stay within 12 months of treatment (30).…”

“…Amongst other factors, advancing age has previously been associated with a higher degree of long term damage and this patient group are potentially more frail with increased susceptibility to any potential treatment related morbidity (29). In a follow-up study of their previously reported cohort, Weiner et al set out to address this by evaluating the potential association between end organ damage and hospitalisation rates with therapy at one and two years (30). In doing so, they identified that amongst patients >75 years the use of cyclophosphamide or rituximab was actually associated with a lower rate of damage (30).…”

“…In a follow-up study of their previously reported cohort, Weiner et al set out to address this by evaluating the potential association between end organ damage and hospitalisation rates with therapy at one and two years (30). In doing so, they identified that amongst patients >75 years the use of cyclophosphamide or rituximab was actually associated with a lower rate of damage (30). As disease severity at presentation is known risk factor for permanent organ damage (29), this finding likely reflects the benefit of attenuated disease activity achieved with therapy.…”

Application of biological agents in the treatment of anti-neutrophil cytoplasmic antibody-associated vasculitis

“…Compared to treatment regimens containing CYC, the use of RTX alone may reduce the risk of bone marrow suppression. Research by Weiner et al (2020) has demonstrated that both CYC and RTX therapies can reduce permanent organ damage in elderly patients with AAV. However, the use of higher doses of glucocorticoids within the first 3 months is associated with treatment-related injuries and fatal infections.…”