Springer Jason M, Kalot Mohamad A, Husainat Nedaa M, Byram Kevin W, Dua Anisha B, James Karen E, Chang Lin Yih, Turgunbaev Marat, Villa-Forte Alexandra, Abril Andy, Langford Carol, Maz Mehrdad, Chung Sharon A, Mustafa Reem A
Vanderbilt University Medical Center, Nashville, Tennessee.
State University of New York at Buffalo.
ACR Open Rheumatol. 2021 Mar;3(3):196-205. doi: 10.1002/acr2.11230. Epub 2021 Feb 16.
The aim of this systemic review is to compare different treatments for patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) to inform evidence-based recommendations for the American College of Rheumatology (ACR)/Vasculitis Foundation (VF) Vasculitis Management Guidelines.
A systemic review was conducted by searching articles in English using OVID Medline, PubMed, Embase, and the Cochrane Library. Articles were screened for suitability in addressing PICO questions, with studies presenting the highest level of evidence given preference.
A total of 729 full-text articles addressing GPA and MPA PICO questions were reviewed. For remission induction, rituximab was shown to be noninferior to cyclophosphamide (CYC) (odds ratio [OR]: 1.55, moderate certainty of evidence). The addition of plasma exchange to induction therapy in severe disease did not improve the composite end point of death or end stage renal disease (hazard ratio [HR]: 0.86 [95% confidence interval CI: 0.65, 1.13], moderate certainty of evidence). In nonsevere disease, methotrexate was noninferior to CYC for induction of remission (remission at 6 months of 90% vs. 94%). For maintenance of remission, methotrexate and azathioprine showed no difference in the risk of relapse over a mean follow-up of 29 months (HR: 0.92, [95% CI: 0.52, 1.65]low certainty of evidence). As maintenance therapy, rituximab was superior to a tapering azathioprine strategy in major relapse-free survival at 28 months (HR: 6.61, [95% CI: 1.56, 27.96], moderate certainty of evidence). In two randomized trials, longer-term azathioprine maintenance therapy (>24 months) is associated with fewer relapses without an increase in adverse events.
This comprehensive systematic review synthesizes and evaluates the benefits and toxicities of different treatment options for GPA and MPA.
本系统评价旨在比较不同治疗方法对肉芽肿性多血管炎（GPA）和显微镜下多血管炎（MPA）患者的疗效，为美国风湿病学会（ACR）/血管炎基金会（VF）血管炎管理指南提供循证建议。
通过使用OVID Medline、PubMed、Embase和Cochrane图书馆检索英文文章进行系统评价。筛选文章是否适合解决PICO问题，优先选择提供最高证据水平的研究。
共审查了729篇涉及GPA和MPA PICO问题的全文文章。在诱导缓解方面，利妥昔单抗被证明不劣于环磷酰胺（CYC）（比值比[OR]：1.55，证据确定性中等）。在重症疾病中，诱导治疗加用血浆置换并未改善死亡或终末期肾病的复合终点（风险比[HR]：0.86[95%置信区间CI：0.65，1.13]，证据确定性中等）。在非重症疾病中，甲氨蝶呤在诱导缓解方面不劣于CYC（6个月时缓解率分别为90%和94%）。在平均29个月的随访中，甲氨蝶呤和硫唑嘌呤在复发风险方面无差异（HR：0.92，[95%CI：0.52，1.65]，证据确定性低）。作为维持治疗，在28个月的无重大复发生存期方面，利妥昔单抗优于逐渐减量的硫唑嘌呤策略（HR：6.61，[95%CI：1.56，27.96]，证据确定性中等）。在两项随机试验中，长期硫唑嘌呤维持治疗（>24个月）与复发减少相关，且不良事件未增加。
本全面的系统评价综合并评估了GPA和MPA不同治疗方案的益处和毒性。
