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Practice patterns of ANCA-associated vasculitis: exploring differences among subspecialties at a single academic medical centre.

ABSTRACT: Clinical trial data help guide physician treatment choices for ANCA-associated vasculitis (AAV), but when data are lacking, treatment choices are largely driven by physician preference. Our aim was to examine AAV treatment preferences to determine if patient gender and age, and physician subspecialty affect treatment choices.Rheumatologists, nephrologists and pulmonologists from an academic medical centre participated in a web-based survey. Three scenarios (remission induction in severe disease; remission maintenance in severe disease; remission induction in limited disease) were presented for 4 patient profiles (28- and 68-year-old female/male). Physician treatment choices and reasons for these choices were obtained. Differences between groups were analysed using Chi-Square and Fisher's exact tests.Physicians were significantly more likely to choose rituximab for young females for remission induction in severe AAV, with toxicity being the main reason for this choice. There was a trend toward rheumatologists choosing rituximab over cyclophosphamide compared with other subspecialties for this scenario. Most physicians switched to a less toxic agent for remission maintenance, but there was little agreement as to choice of maintenance therapy among subspecialties. For remission induction in limited disease, most physicians chose rituximab, particularly for young females.Currently, there are very few data for remission maintenance therapy following rituximab in severe disease, as well as the use of rituximab in limited disease. Choices for treatment of AAV differ among subspecialties, are affected by patient gender and age, and tend to be largely driven by physician preference when data are limited or lacking.

SUBMITTER: Forbess LJ

PROVIDER: S-EPMC4315329 | biostudies-literature | 2014 May-Jun

REPOSITORIES: biostudies-literature

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Practice patterns of ANCA-associated vasculitis: exploring differences among subspecialties at a single academic medical centre.

Forbess Lindsy J LJ Griffin Kenneth W KW Spiera Robert F RF

Clinical and experimental rheumatology 20140516 3 Suppl 82

<h4>Objectives</h4>Clinical trial data help guide physician treatment choices for ANCA-associated vasculitis (AAV), but when data are lacking, treatment choices are largely driven by physician preference. Our aim was to examine AAV treatment preferences to determine if patient gender and age, and physician subspecialty affect treatment choices.<h4>Methods</h4>Rheumatologists, nephrologists and pulmonologists from an academic medical centre participated in a web-based survey. Three scenarios (rem ...[more]

PMID: 24854372

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Project description:Antineutrophil cytoplasm antibody (ANCA)-associated vasculitides are small-vessel vasculitides that include granulomatosis with polyangiitis (formerly Wegener's granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Renal-limited ANCA-associated vasculitides can be considered the fourth entity. Despite their rarity and still unknown cause(s), research pertaining to ANCA-associated vasculitides has been very active over the past decades. The pathogenic role of antimyeloperoxidase ANCA (MPO-ANCA) has been supported using several animal models, but that of antiproteinase 3 ANCA (PR3-ANCA) has not been as strongly demonstrated. Moreover, some MPO-ANCA subsets, which are directed against a few specific MPO epitopes, have recently been found to be better associated with disease activity, but a different method than the one presently used in routine detection is required to detect them. B cells possibly play a major role in the pathogenesis because they produce ANCAs, as well as neutrophil abnormalities and imbalances in different T-cell subtypes [T helper (Th)1, Th2, Th17, regulatory cluster of differentiation (CD)4+ CD25+ forkhead box P3 (FoxP3)+ T cells] and/or cytokine-chemokine networks. The alternative complement pathway is also involved, and its blockade has been shown to prevent renal disease in an MPO-ANCA murine model. Other recent studies suggested strongest genetic associations by ANCA type rather than by clinical diagnosis. The induction treatment for severe granulomatosis with polyangiitis and microscopic polyangiitis is relatively well codified but does not (yet) really differ by precise diagnosis or ANCA type. It comprises glucocorticoids combined with another immunosuppressant, cyclophosphamide or rituximab. The choice between the two immunosuppressants must consider the comorbidities, past exposure to cyclophosphamide for relapsers, plans for pregnancy, and also the cost of rituximab. Once remission is achieved, maintenance strategy following cyclophosphamide-based induction relies on less toxic agents such as azathioprine or methotrexate. The optimal maintenance strategy following rituximab-based induction therapy remains to be determined. Preliminary results on rituximab for maintenance therapy appear promising. Efforts are still under way to determine the optimal duration of maintenance therapy, ideally tailored according to the characteristics of each patient and the previous treatment received.

Project description:OBJECTIVE:To determine the prevalence and associated factors for personal, work-related and patient/client-related burnout in clinical professionals and biomedical scientists in academic medicine. DESIGN:Prevalence survey using the Copenhagen Burnout Inventory. SETTING:Mid-size academic health centre. PARTICIPANTS:Clinical providers (n=6489) and biomedical scientists (n=248) were invited to complete the survey. 1646 completed responses (response rate 24.4%) were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES:Prevalence estimates and adjusted ORs (AOR) were stratified for gender, age and professional category. RESULTS:Type of burnout varies across professional categories, with significant differences between clinicians and scientists. The prevalence of personal burnout was 52.7% (95%CI 50% to 55%), work-related burnout 47.5% (95%CI 45% to 49%) and patient/client-related burnout 20.3% (95%CI 18% to 22%). The prevalence of personal and work-related burnout was higher among women, while those aged 20-30 had a higher prevalence of all three burnout categories. Overall, clinical professionals had higher personal and work-related burnout, while biomedical scientists had higher client-related burnout. Accounting for the effects of gender and age, a significantly higher risk for personal burnout was found for physicians (AOR 1.64; 95%CI 1.3 to 2.1) and nurses (AOR 1.5; 95%CI 1.03 to 2.2). Significantly higher odds of work-related burnout were found for nurses (AOR 1.5; 95%CI 1.2 to 1.9) and residents (AOR 1.9; 95%CI 1.04 to 3.6). Basic scientists (AOR 10.0; 95%CI 5.7 to 17.6), physicians (AOR 2.8; 95%CI 1.9 to 4.1) and nurses (AOR 2.1; 95%CI 1.3 to 3.5) had higher odds of patient/client-related burnout. CONCLUSIONS:Types of burnout are unevenly distributed in academic medical centres. Physicians have higher risk of personal and patient/client-related burnout, residents have higher risk of work-related burnout, basic scientists are at higher risk of client-related burnout and nurses have higher odds of all three types of burnout. Interventions addressing the problem of burnout in clinical environments may be inadequate to support biomedical scientists.

Project description:BACKGROUND:Cyclophosphamide and glucocorticoids have been the cornerstone of remission-induction therapy for severe antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis for 40 years. Uncontrolled studies suggest that rituximab is effective and may be safer than a cyclophosphamide-based regimen. METHODS:We conducted a multicenter, randomized, double-blind, double-dummy, noninferiority trial of rituximab (375 mg per square meter of body-surface area per week for 4 weeks) as compared with cyclophosphamide (2 mg per kilogram of body weight per day) for remission induction. Glucocorticoids were tapered off; the primary end point was remission of disease without the use of prednisone at 6 months. RESULTS:Nine centers enrolled 197 ANCA-positive patients with either Wegener's granulomatosis or microscopic polyangiitis. Baseline disease activity, organ involvement, and the proportion of patients with relapsing disease were similar in the two treatment groups. Sixty-three patients in the rituximab group (64%) reached the primary end point, as compared with 52 patients in the control group (53%), a result that met the criterion for noninferiority (P<0.001). The rituximab-based regimen was more efficacious than the cyclophosphamide-based regimen for inducing remission of relapsing disease; 34 of 51 patients in the rituximab group (67%) as compared with 21 of 50 patients in the control group (42%) reached the primary end point (P=0.01). Rituximab was also as effective as cyclophosphamide in the treatment of patients with major renal disease or alveolar hemorrhage. There were no significant differences between the treatment groups with respect to rates of adverse events. CONCLUSIONS:Rituximab therapy was not inferior to daily cyclophosphamide treatment for induction of remission in severe ANCA-associated vasculitis and may be superior in relapsing disease. (Funded by the National Institutes of Allergy and Infectious Diseases, Genentech, and Biogen; ClinicalTrials.gov number, NCT00104299.)

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Practice patterns of ANCA-associated vasculitis: exploring differences among subspecialties at a single academic medical centre.

Publications

Practice patterns of ANCA-associated vasculitis: exploring differences among subspecialties at a single academic medical centre.

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