Rituximab Versus Conventional Therapy for Remission Induction in Eosinophilic Granulomatosis With Polyangiitis
A Randomized Controlled Trial
- Terrier, Benjamin MD, PhD
- Pugnet, Grégory MD, PhD
- de Moreuil, Claire MD, PhD
- Bonnotte, Bernard MD, PhD
- Benhamou, Ygal MD, PhD
- Chauveau, Dominique MD, PhD
- Besse, Marie-Charlotte MD
- Duffau, Pierre MD, PhD
- Limal, Nicolas MD
- Néel, Antoine MD, PhD
- Urbanski, Geoffrey MD, PhD
- Jourde-Chiche, Noémie MD, PhD
- Martin-Silva, Nicolas MD
- Campagne, Julien MD
- Mekinian, Arsène MD, PhD
- Schleinitz, Nicolas MD, PhD
- Ackermann, Felix MD
- Fauchais, Anne-Laure MD, PhD
- Froissart, Antoine MD
- Gallou, Thomas Le MD
- Uzunhan, Yurdagul MD, PhD
- Viallard, Jean-François MD, PhD
- Bérezné, Alice MD
- Chiche, Laurent MD, PhD
- Taillé, Camille MD, PhD
- Direz, Guillaume MD
- Durel, Cécile-Audrey MD
- Godmer, Pascal MD
- Trad, Salim MD, PhD
- Lambert, Marc MD, PhD
- de Menthon, Mathilde MD, PhD
- Quéméneur, Thomas MD
- Cadranel, Jacques MD, PhD
- Charles, Pierre MD, PhD
- Dossier, Antoine MD
- Jilet, Léa MD
- Guillevin, Loïc MD
- Abdoul, Hendy MD
- Puéchal, Xavier MD, PhD
Background:
Eosinophilic granulomatosis with polyangiitis (EGPA) is an eosinophilic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Rituximab has emerged as the standard of care in other types of ANCA-associated vasculitis, but controlled studies on its use in EGPA are yet lacking.
Objective:
To compare rituximab with conventional strategy for the induction of remission in patients with EGPA.
Design:
Phase 3, multicenter, randomized, controlled, double-blind, superiority trial. (ClinicalTrials.gov: NCT02807103)
Setting:
France.
Participants:
Patients with a diagnosis of EGPA, newly diagnosed or relapsing disease at the time of screening, with active disease defined as a Birmingham Vasculitis Activity Score (BVAS) of 3 or greater.
Intervention:
Glucocorticoids plus rituximab (1 g 2 weeks apart) compared with the conventional strategy (glucocorticoids alone or in combination with cyclophosphamide in severe forms) for induction of remission.
Measurements:
The primary end point was remission defined as a BVAS, version 3, of 0 and a prednisone dose of 7.5 mg/d or less at day 180. Secondary end points included duration of remission during the study, average daily glucocorticoid dose, and safety.
Results:
A total of 105 participants were randomly assigned. Thirty-three (63.5%) patients in the rituximab group achieved the primary end point compared with 32 (60.4%) in the control group (relative risk, 1.05 [95% CI, 0.78 to 1.42]; P = 0.75). Results were similar at day 360. The mean duration of remission was 48.5 ± 6.51 weeks in the rituximab group and 49.1 ± 7.42 weeks in the conventional strategy group (P = 0.41). All relapse and major relapse rates were similar between the 2 groups. There was no statistically significant difference in the average daily glucocorticoid dose and no statistically significant differences in the rates of adverse events between the treatment groups.
Limitation:
Design not appropriate to answer the question of equivalence between rituximab and cyclophosphamide in patients with severe EGPA.
Conclusions:
Rituximab was not superior to a conventional remission induction strategy in EGPA.
Primary Funding Source:
French Ministry of Health.
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is an eosinophilic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Prognosis has improved with the use of glucocorticoids and immunosuppressants, such as cyclophosphamide, but these therapies carry significant toxicities. Although rituximab has been shown to be noninferior to cyclophosphamide in other forms of ANCA-associated vasculitis, it has not been specifically studied in EGPA. To address this gap, this phase 3, multicenter, randomized, double-blind, controlled superiority trial compared glucocorticoids plus rituximab with the conventional induction strategy.
Visual Abstract: Rituximab Versus Conventional Therapy for Remission Induction in Eosinophilic Granulomatosis With Polyangiitis
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is an eosinophilic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Prognosis has improved with the use of glucocorticoids and immunosuppressants, such as cyclophosphamide, but these therapies carry significant toxicities. Although rituximab has been shown to be noninferior to cyclophosphamide in other forms of ANCA-associated vasculitis, it has not been specifically studied in EGPA. To address this gap, this phase 3, multicenter, randomized, double-blind, controlled superiority trial compared glucocorticoids plus rituximab with the conventional induction strategy.