‘Favorable Outcomes’ with Treatment Likely for Older Adults with AAV, Study Finds

Older adults with ANCA-associated vasculitis (AAV) have an overall good prognosis, with a high long-term survival rate, a recent study suggests.

Higher frailty scores and elevated levels of C-reactive protein (CRP), an inflammatory marker, were identified as factors associated with mortality.

The study, “Long-term outcomes in elderly patients with ANCA-associated vasculitis,” was published in Rheumatology.

AAV, characterized by the inflammation and destruction of small blood vessels, can occur at any age. However, its incidence is higher in people in their 70s and 80s.

Both AAV itself and the medications used to treat it can take a particularly hard toll on older people. But those over the age of 65 are under-represented in studies of AAV, making it unclear what the prognosis is for older people with AAV.

Moreover, studies on the prognosis and age of patients were conducted “in an era pre-dating the widespread use of rituximab [Rituxan],” the researchers wrote.

“It is important to accurately define the outcomes of AAV in the elderly so that doctors, patients and their families are able to make informed choices about treatment,” they added.

The team analyzed data for people with AAV age 65 or older, who were treated at the Royal Infirmary of Edinburgh clinic between 2005 and 2017. This included data for 83 people, who were followed up with for a median of 1,203 days (a little over three years). The group’s median age was 74 (range 68 – 84), and 63% were female.

The researchers described the treatments common in this group — nearly all (96%) took oral prednisolone (a glucocorticoid), and about a third received cyclophosphamide-based and/or rituximab-based induction treatments (39% and 37%, respectively). Ten patients (12%) were using mycophenolate mofetil (CellCept, MMF) and other 10 (12%) being given alternative glucocorticoid-sparing agents

Over the course of follow-up, 70 people went into clinical remission, followed by at least one relapse  in 16 of them.

The most common treatment-related adverse events reported was serious infections, totaling 44 of the 74 treatment-related adverse event recorded.

Mortality did not significantly differ among people on different treatments, although it was “marginally lower in the cyclophosphamide group,” the researchers wrote. Of note, patients that received this treatment tended to be younger and had better renal function at baseline.

Among these 83 patients in this study, the two-year survival rate was 83%, and 75% at five years. The researchers noted that all the deaths occurred in people over the age of 75.

Researchers also analyzed factors to see which ones were associated with a greater mortality risk. Unsurprisingly, age was one such factor. The other two factors that had statistically significant effects were frailty and CRP levels. CRP is a protein in the blood that is commonly measured in lab tests; high levels of CRP are indicative of inflammation.

Frailty was measured with the Canadian Study on Health and Ageing Clinical Frailty Scale (also known as Rockwood’s Clinical Frailty Scale). This is a nine-point scale, with higher scores indicating a lesser ability to function independently. Based on their statistical analysis, “for each additional point on the frailty score, the risk of death approximately doubled,” the researchers wrote.

“That a frailty score was also associated with mortality — even after adjusting for age and other potentially confounding variables — suggests that this simple tool might provide useful additional information about elderly patients with ANCA vasculitis,” they added, noting that the fragility scale represents “a free, accessible and rapid tool to allow prognostication in elderly patients presenting with AAV.”

This study only assessed people who were treated at a single specialty clinic and as such, the researchers wrote, “our findings cannot be extrapolated widely without replication.”

Nonetheless, they concluded that, “[i]n the contemporary era, the overall prognosis of AAV in elderly patients is good.”

“Cyclophosphamide, rituximab and MMF are all valid treatment options in the elderly. A low-dose glucocorticoid regimen (in which intravenous methylprednisolone is not routinely used) can be used to treat AAV in elderly patients, with favourable outcomes,” they added.