Low-dose Glucocorticoid Regimen May Effectively Treat AAV in Elderly Patients, Study Suggests

A low-dose glucocorticoid regimen, in which intravenous methylprednisolone (a type of steroid) is not routinely used, can be used to effectively treat ANCA-associated vasculitis in elderly patients, a new study shows.

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

ANCA-associated vasculitis (AAV) is a small-vessel vasculitis that can occur at any age, though its incidence peaks in people over the age of 70. Elderly patients are particularly vulnerable to the adverse effects of this disease and the immunosuppressive agents used to treat it. However, there is lack of AAV research in this patient population as elderly patients are under-represented in clinical trials.

Thus, doctors don’t have the necessary information to make the appropriate decisions about treatment for elderly patients with AAV.

“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,” the study said.

Therefore, a group of researchers in Scotland set out to assess long-term outcomes in a “real-world” cohort of AAV patients who were at least 65 years old and treated at a vasculitis center between 2005 and 2017.

The researchers also hypothesized that a baseline frailty score (a measure of health status in older individuals) could provide prognostic information.

The study included 83 patients who were followed for a median of 1,203 days (approximately 3 years and 4 months). The median age of patients was 74 years.

During follow-up, 70 patients achieved remission, 16 of whom relapsed, and 21 patients died. At two years, 83% of patients were alive, and 75% reached the five-year mark, which is an overall good prognosis for this population.

“To put this into context, the two-year survival of a Scottish 74-year-old is [approximately] 94% in the general population. For Scottish adults with type 1 diabetes mellitus, two-year survival in this age group is [approximately] 86%,” the researchers said.

The study found that age, a higher frailty score, and very elevated markers of inflammation were all associated with an increased risk of death.

The frailty score was also associated with more adverse events and longer hospital stays, and thus has the potential to “provide a free, accessible and rapid tool to allow prognostication in elderly patients presenting with AAV,” the researchers wrote.

Patients receiving cyclophosphamide appeared to live longer than those on rituximab or mycophenolate mofetil, but they were also younger and with better kidney function at study baseline.

The median cumulative dose of oral prednisolone (a steroid medication) was 2 g during the first three months, and one patient received intravenous (into the vein) glucocorticoids.

“Our favourable outcomes add to the growing weight of evidence that glucocorticoid doses can be safely minimized in AAV,” the researchers wrote. “They also suggest that — particularly in elderly patients — intravenous methylprednisolone is not a necessary component of induction immunosuppression for the vast majority of patients.”

“In the contemporary era, the overall prognosis of AAV in elderly patients is good. Baseline frailty associates with disease outcomes including mortality,” the investigators stated. “A low-dose glucocorticoid regimen (avoiding intravenous methylprednisolone) can be used to treat AAV effectively in elderly patients.”