The Role of Mycophenolate Mofetil for the Induction of Remission in ANCA-Associated Vasculitis: A Meta-Analysis

Abstract

Objectives: The successful introduction of mycophenolate mofetil (MMF) as a treatment for renal allograft reduced the incidence of acute rejection. The inspiring effects obtained by the MMF have led to an evaluation of its therapeutic potency on ANCA-associated vasculitis (AAV). However, there is little evidence of the MMF's efficacy on the AAV. The meta-analysis is carried out to evaluate the efficacy of MMF as a remission induction therapy in AAV.Methods: Up to June 30th, 2020, PubMed, Cochrane Library, and Embase have been searched comprehensively. According to heterogeneity, the pooled remission rates are synthesized by either fixed-effect or random-effect models.Results: The eight included studies comprising 230 patients who were treated with MMF as induction therapy are included in our analysis. The pooled overall remission rate is 74% (95% CI: 0.68–0.80). The remission rate, the infection rate and the rate of leukopenia of four randomized controlled trials aimed at comparing the effects of MMF with cyclophosphamide (CYC) during induction therapy for AAV have no statistical significance (P > 0.05).Conclusion: MMF may be an alternative to CYC for remission induction therapy in AAV with MPO-ANCA, mild to moderate renal involvement and non-life-threatening state. Whether to observe the effect of MMF in AAV or to compare the difference between MMF and CYC in the future studies, risk stratification and subgrouping of AAV patients should be first carried out to correctly identify the AAV subgroup suitable for MMF.

Management of antineutrophil cytoplasmic antibody–associated vasculitis with glomerulonephritis as proposed by the ACR 2021, EULAR 2022 and KDIGO 2021 guidelines/recommendations

“…MYCYC, an RCT comparing MMF with CYC showed non-inferiority of MMF in inducing remission at 6 months although relapses occurred more frequently in patients with proteinase 3 (PR3)-ANCA vasculitis treated with MMF [ 46 ]. A recent meta-analysis underlines that MMF may play a particular role in patients with myeloperoxidase (MPO)-ANCA with mild to moderate kidney involvement [ 49 ].…”

“…AZA or methotrexate (MTX) (in patients with eGFR >60 mL/min/1.73 m 2 ) or MMF are viable alternatives for patients in which RTX cannot be used, or in patients with non-severe GPA/MPA [ 15 ]. While KDIGO mention a meta-analysis indicating that a longer course of GC may be associated with fewer relapses [ 49 ], all the panels agree that GC tapering should occur as early as possible, accepting that a small number of patients will remain on a low GC dose longer-term. The best strategy for GC tapering in remission-maintenance is under review in The Assessment of Prednisone in Remission Trial (TAPIR) and MAIPENSAN studies.…”

Incidence of serious infections in patients with ANCA-associated vasculitis receiving immunosuppressive therapy: A systematic review and meta-analysis

“…Following induction, maintenance of remission in patients with severe disease is usually achieved by the administration of azathioprine, or rituximab (4). Other agents such as methotrexate (7) and mycophenolate mofetil (8) are usually reserved for patients with non-severe limited disease (4).…”