Relapses of ANCA-associated vasculitis (AAV) have been linked to an increase in death, reduced kidney (renal) function and end-stage renal disease (ESRD). Long-term use of steroid medications is often used to help keep AAV under control.
However, there are concerns about adverse effects of the medicines, so patients and physicians have to walk a tight rope to lower the steroid dosage without triggering a relapse of the disease.
An abstract presented at the 2017 Annual Meeting of the American College of Rheumatology looked at some of these issues.
Lack of Data When Stopping Steroids
“There is still a lack of data on when to stop steroid maintenance therapy when people have their disease well controlled,” said Amy Archer, MD, PhD, an assistant professor at Northwestern University and director of the NW Vasculitis Center.
“If we stop the steroids too early, their vasculitis may flare and they need steroid doses that are much higher than maintenance to get it back under control.”
To learn more about long-term steroid usage, Jennifer Rodrigues, MD, MSc, a nephrologist and VCRC-VF clinical research fellow at McMaster University, Dr. Archer, and colleagues reviewed 24 studies published between 2008 and 2016.
Of these 13 studies (54%) had stopped steroid treatment within one year They studied the records of 2,272 patients. All the patients received immunotherapy in addition to the prescribed steroids to achieve remission.
“Best Worst Medicine”
“We often call steroids our ‘best worst medicine,” says Dr. Archer. “Steroids work fast to decrease inflammation, but since they have so many side effects, particularly at high doses, most patients want to get off them if they can. This study tries to help clarify if there is a benefit to keeping patients with ANCA-associated vasculitis on low levels of steroid medication.”
Relapse was more frequent with complete discontinuation of steroid medications at any one time when compared to long-term, low-dose maintenance therapy.
This was confirmed by other statistical methods also showing long-term, low-dose steroid use was associated with lower relapse rates.
Overall follow-up time was linked to an increase in relapse rates. Other variables such as time to discontinuation of non-steroid immunotherapy, time to steroid discontinuation, renal function, and presence of relapse at baseline, did not show any significant association with relapse rates.
Benefit of Long-Term Treatment
“In studies where the doctors took people off of steroids, there were more relapses than seen in those studies where patients were left on at least a low dose of steroid,” says Dr. Archer. “Although this is not a prospective randomly controlled trial, it does provide additional clarity on the benefit of keeping patients with ANCA-associated vasculitis on maintenance doses of steroids long term.”
The Steroid Tapering in ANCA Vasculitis Evaluation Study (STAVE) 2: A Systematic Review and MetaAnalysis https://acrabstracts.org/abstract/the-steroid-tapering-in-anca-vasculitis-evaluation-study-stave-2-a-systematic-review-and-meta-analysis/