Rituximab cuts recurrence risk in subglottic stenosis surgery: Study

Small study finds treatment superior to other immunosuppressants

Marisa Wexler, MS avatar

by Marisa Wexler, MS |

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A patient chooses between a pill and an injection, figuratively weighing them with one on each hand.

Rituximab is superior to other immunosuppressive treatments at preventing post-surgery relapse in granulomatosis with polyangiitis (GPA) patients undergoing surgery to address subglottic stenosis, a common complication that causes airway narrowing.

That’s according to a study that analyzed data from 25 GPA patients who were followed for more than 12 years, on average, after surgery.

“This study presents valuable insights into the management of GPA‐associated SGS [subglottic stenosis],” the researchers wrote.

The study, “Medical Maintenance Therapy Following Laser Excision in Patients With Granulomatosis With Polyangiitis (GPA)-Associated Subglottic Stenosis,” was published in Otolaryngology—Head and Neck Surgery.

GPA is a form of ANCA-associated vasculitis that’s typically characterized by blood vessel inflammation in the airways, lungs, and kidneys. The autoimmune disease has been historically classified as systemic, when involving organs outside of the respiratory tract, or limited, when restricted to the lungs, throat, nose, and associated tissues.

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Lack of guidelines for subglottic stenosis management

One of the most common upper airway manifestations of GPA is subglottic stenosis, in which the part of the throat right above the windpipe becomes narrowed, making it harder to breathe. It is estimated to affect as many as 23% of GPA patients.

“GPA-associated SGS frequently exhibits treatment resistance, and currently, there remains a lack of well-defined clinical guidelines for its management,” the researchers wrote. Previous studies suggested that combining endoscopic surgery and immunosuppressive treatment results in “the most favorable outcomes,” they wrote.

Endoscopic surgery is a minimally invasive surgery that involves inserting through the mouth a thin, flexible tube with a tiny camera on the end, along with other selected tools, such as a laser.

A team led by scientists at the Mayo Clinic reported on outcomes from 25 GPA patients with subglottic stenosis who underwent CO2 laser-assisted endoscopic excision — a surgery to remove the extra tissue that is narrowing the airway — at their institution.

The patients, 15 women and 10 men, had a mean age of 40, and were followed for a mean of 12.6 years. Most (64%) had limited GPA, and nearly a quarter (24%) had undergone previous surgical intervention for subglottic stenosis at other institutions.

All patients were on immunosuppressive therapy before CO2 laser-assisted endoscopic excision. A total of 44% were on rituximab, a medication that works to kill B-cells, the type of immune cell that produces antibodies, including those that drive GPA.

The surgical procedure was performed without any major issues, and all patients reported notable reductions in subglottic stenosis-related symptoms following the operation.

That suggests that this type of surgery is “a safe local intervention providing immediate symptomatic improvement in patients with … GPA-associated SGS,” the researchers wrote.

After the surgery, 15 patients (60%) — 63% with limited GPA and 56% with systemic GPA — were treated with rituximab. Seven of these were also given the corticosteroid prednisone, which was tapered off in the following months.

The remaining 10 patients received other immunosuppressive treatments, taking either azathioprine, methotrexate, mercaptopurine, or prednisone alone.

In the years following surgery, a significantly lower proportion of patients on rituximab experienced subglottic stenosis recurrence that needed a repeat endoscopic intervention compared with those on other immunosuppressive medications (47% vs. 90%).

No significant group differences were observed in terms of average time to recurrence.

Further statistical analyses showed that people with limited GPA were significantly more likely, by nearly 2.5 times, to experience disease recurrence than those with systematic disease (81% vs. 33%).

“Our data suggests that medical maintenance therapy with rituximab following endoscopic laser excision leads to decreased recurrence rates compared to medical therapy with nonrituximab agents,” the researchers wrote.

The findings “suggest a potential benefit in using endoscopic intervention and rituximab therapy concurrently for GPA‐associated SGS,” they added.

The team noted that their study was limited by the small number of patients, and they stressed a need for further efforts to develop guidelines for optimal long-term management of subglottic stenosis for people with GPA.

“Further research with larger [patient groups] and standardized treatment protocols is warranted to expand our understanding and refine therapeutic approaches for this rare and complex condition,” they concluded.