Maintaining remission in ANCA-associated vasculitides

At 4 to 6 months of treatment, assess if remission has been achieved with intensive induction therapy. Consider if cyclophosphamide can be replaced with less toxic maintenance therapy.

For maintenance of remission in ANCA-associated vasculitides, combination therapy is used (systemic corticosteroids plus a corticosteroid-sparing immunomodulatory drug). The most commonly used corticosteroid-sparing drug(s):

for eosinophilic granulomatosis with polyangiitis (EGPA) is azathioprine
for granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) are azathioprine, rituximab, methotrexate or mycophenolate mofetil.

If azathioprine is indicated for maintenance therapy in ANCA-associated vasculitides, use:

azathioprine 50 to 100 mg orally, daily initially, increasing to 2 mg/kg up to 200 mg orally, daily. azathioprine azathioprine azathioprine

For additional considerations specific to azathioprine use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

Rituximab is sometimes indicated for maintenance therapy in ANCA-associated vasculitides; dosing should be guided by a specialist.

If methotrexate is indicated for maintenance therapy in ANCA-associated vasculitides, use:

1methotrexate 10 to 25 mg orally, on one specified day once weekly methotrexate methotrexate methotrexate

1methotrexate 10 to 25 mg subcutaneously, on one specified day once weekly methotrexate methotrexate methotrexate

PLUS with either of the above

folic acid 5 to 10 mg orally, weekly (not on the same day as methotrexate). folic acid folic acid folic acid

For additional considerations specific to methotrexate use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

If mycophenolate mofetil is indicated for maintenance therapy in ANCA-associated vasculitides, use:

mycophenolate mofetil 1500 to 3000 mg orally, daily in 2 divided doses. mycophenolate mofetil mycophenolate mofetil mycophenolate mofetil

For additional considerations specific to mycophenolate mofetil use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).