The 2020 ACR Review Course: Key Issues Rheumatologists Face

ACR CONVERGENCE 2020—The field of rheumatology is vast, with innumerable diseases to consider in each differential and with myriad possible presentations of each condition. Summarizing the key issues relating to specific diseases is quite challenging, yet the speakers in the Review Course discussed a diverse field of subjects: vasculitis, osteoporosis, liver disease, pregnancy and rheumatic disease, pediatric rheumatology, seronegatives and psoriatics, rheumatoid arthritis and lupus nephritis, and did so with a balance between details and the big picture.

Landmark Vasculitis Studies
Philip Seo, MD, MHS, associate professor of medicine and director of the Johns Hopkins Vasculitis Center at Johns Hopkins University, Baltimore, as well as the physician editor of The Rheumatologist, delivered a lecture focused on an in-depth understanding of several landmark vasculitis studies in recent years.

On large vessel vasculitis, Dr. Seo discussed the finer points of the Giant-Cell Arteritis Actemra (GiACTA) trial, a phase 2, randomized, placebo-controlled study in which a significantly larger number of patients with giant cell arteritis (GCA) receiving tocilizumab, either every week or every other week, achieved steroid-free remission at 52 weeks as compared with placebo.¹

This study provided the main evidence that supported approval of tocilizumab as a treatment for GCA by the U.S. Food & Drug Administration (FDA) in 2017. Dr. Seo noted several interesting findings from the study, including that although both weekly and every other week tocilizumab were efficacious for patients with a new diagnosis of GCA, weekly tocilizumab was associated with greater improvements in fatigue and quality of life and appears to be more efficacious for patients with relapsing disease.

A long-term follow up study of the GiACTA trial has also demonstrated that one year of treatment with tocilizumab may be associated with decreased long-term rates of relapse.²

For anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis, Dr. Seo described the three MAINRITSAN trials. The first MAINRITSAN trial found that 500 mg of rituximab every six months is more effective than 2 mg/kg/day of azathioprine for remission maintenance in ANCA-associated vasculitis.³

MAINRITSAN-2 showed that 500 mg of rituximab every six months is as effective as an individually tailored regimen of rituximab—500 mg at randomization, then reinfusion only when CD19+B lymphocytes or ANCA had reappeared or ANCA titer rose markedly based on trimestrial testing until month 18.⁴

MAINRITSAN-3 demonstrated that 500 mg of rituximab every six months is effective for remission maintenance for at least four years.⁵  

Dr. Seo also discussed the Plasma Exchange and Glucocorticoids in Severe ANCA-Associated Vasculitis (PEXIVAS) study, which showed that, in general, plasma exchange does not benefit patients with ANCA-associated vasculitis, and the Mepolizumab in Relapsing or Refractory Eosinophilic Granulomatosis with Polyangiitis [EGPA] (MIRRA) study, which demonstrated efficacy of mepolizumab in the treatment of EGPA.^6,7