Granulomatosis with Polyangiitis (GPA/formerly Wegener’s Granulomatosis)
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Granulomatosis with polyangiitis (GPA/formerly called Wegener’s granulomatosis) is systemic, meaning that the effect of inflammation can be present in the entire body. It affects the upper (sinuses and nose), and lower (lungs), respiratory system and frequently involves the kidneys, lungs, eyes, ears, throat, skin and other body organs. For unclear reasons, blood vessels in affected areas may become inflamed, and clusters of certain cells (granulomas) may occur. Patients who do not have involvement of the kidney, brain or gut are said to have Limited GPA. However, using the term “limited” has become unpopular because certain forms of the illness may still be very serious even though these other organs are not involved.
As awareness of GPA grows, more patients are diagnosed in the early stages of the disease when effective treatment can result in early remission and prevent organ failure.
Who gets GPA?
GPA is not a common disease, and can occur at any age. It most often occurs in the 4th and 5th decade of life. Patients are divided equally between males and females. It appears that Caucasians are far more commonly affected than other racial groups.
The onset of GPA may be slow moving with few symptoms, or rapid and severe.
About 90% of patients have symptoms of a ‘cold,’ ‘runny nose’ or sinusitis that fail to respond to the usual therapeutic measures and last considerably longer than normal upper respiratory tract infections.
Not all patients with GPA experience all symptoms, and the severity of the disease is also different for each patient. If any of the symptoms listed below persist, consider a possible diagnosis of GPA and arrange to have a complete evaluation, including health history, physical exam, laboratory studies, including a urinalysis and an ANCA test.
- arthritic joint pain
- blood in urine (which may or may not be indicated by a change in urine color)
- cough (with or without the presence of blood)
- inflammation of the ear with hearing problems
- inflammation of the eye with vision problems
- lack of energy
- loss of appetite
- nasal membrane ulcerations and crusting
- night sweats
- numbness of limbs
- pleuritis (inflammation of the lining of the lung)
- rash and/or skin sores
- saddle-nose deformity
- weakness, fatigue
- weight loss
The diagnosis of GPA is established by clinical and laboratory findings such as the ANCA blood test, other blood and urine tests, x-rays, and tissue biopsy, if needed.
Antineutrophil Cytoplasmic Antibody (ANCA) is an abnormal protein. ANCA is part of a large family of molecules called immunoglobulins, (including antibodies), that are made by all animals and are normally intended to protect you. There are two types of ANCA: ‘c’ (cytoplasmic), and ‘p’ (perinuclear). The great majority of patients with GPA test positive for c-ANCA while a small percentage of patients test positive for both ‘p’-and ‘c’- ANCA. C-ANCA reacts with a normal human enzyme contained in white blood cells (called proteinase 3 or PR3), and has a yellow-green pattern in the cell fluid called the cytoplasm, hence the term c-ANCA. The quantity of c-ANCA roughly correlates with disease activity. Very rarely, C-ANCA can be found in other diseases and even in some normal individuals.
The c-ANCA/PR3 antibody test is a helpful diagnostic tool that is used most effectively when patients are thought to possibly have GPA. A positive test is supportive of the diagnosis. However, occasionally the test is negative but GPA is present. Some physicians use the ANCA test to monitor treatment and disease status. Test results by themselves do not always indicate that the disease is active, so that physicians cannot use them as the primary guide to decision making about treatment. Decisions to change treatment should be based on convincing features of GPA disease activity or remission, and appropriate laboratory tests including urinalysis.
The treatment of GPA can be divided into two stages: first, the induction of disease remission, and second, the maintenance of disease remission. Medications used to treat the disease usually include glucocorticoids (prednisone), rituximab (a so-called biologic drug), cyclophosphamide (a chemotherapy or cytotoxic medication), methotrexate, azathioprine (Imuran), mycophenolate mofetil (CellCept).
Treatment will vary based on patient symptoms, disease activity, organ involvement and lab test results. Patients with kidney involvement and more severe GPA are commonly prescribed high dose prednisone in combination with rituximab or cyclophosphamide as initial treatment. Ideally, the use of cyclophosphamide will be limited to a three to six month period and then replaced, based on kidney function, by methotrexate or azathioprine or mycophenolate mofetil.
Effective treatment should include a “team approach” with medical specialists according to the patient’s organ involvement. It is common for a patient with GPA to regularly see the following kinds of specialist doctors: Nephrologist (Kidney), Otolaryngologist (Ear, Nose/Sinus, Throat), Ophthalmologist (Eye), Pulmonologist (Lung), and almost always a Rheumatologist or Immunologist. Other specialists are involved as needed.
To help manage their disease, patients with GPA must maintain a good relationship with their doctors and understand and follow instructions carefully. Many patients find it useful to maintain a diary listing medications, test results and notes on any symptoms they are experiencing. These notes should be reviewed during a patient/doctor appointment. It is imperative to have a close, continuous and long-term doctor follow-up, even when in remission and off therapy, as relapses or flare-ups are common and occur in over 50% of patients as time goes on.
There is no cure for GPA, but early diagnosis and proper treatment is effective in reducing the symptoms of the disease and improving the quality of life and life expectancy of patients who suffer from it. The disease can be brought into remission with complete absence of all signs of disease.
Long-term remission can be induced and maintained with medications, close management and regular lab tests to help monitor the disease. Treatment can produce symptom-free intervals of 5 to 20 years or more. Some patients will achieve a drug-free remission. However, relapses are common but can be caught at their earliest and most treatable stage, for most patients, by paying attention to patient symptoms and lab tests. Patients with GPA who are in remission must not hesitate to see a doctor if any GPA symptoms return or if they are not feeling well.
The past, present and future
The medical community believes GPA is not so rare, but rarely diagnosed. In areas where doctors are aware of the disease, more patients are diagnosed and treated. Early diagnosis and treatment are essential to improve patient outcomes and prevent organ failure.
GPA treatment has come a long way. In 1958, patients with GPA had an 82% mortality rate at one year, with an average patient survival of five months. During the early 1970’s, innovations in treatment pioneered by the National Institutes of Health in Bethesda, Maryland changed the course of GPA treatment remarkably by introducing the use of cyclophosphamide and prednisone in combination. This new approach improved survival rates dramatically to over 90%. However, treatment side effects and drug toxicity presented new challenges. The availability of rituximab (Rituxan) is a further advance in the treatment of GPA. Today, drug toxicity is managed more carefully and long-term remissions are possible. Some patients are able to lead relatively normal lives and have been in remission for 20+ years after treatment!
Research into new medications, treatment options and the cause of GPA are being conducted at leading medical centers throughout the world. Of course, more needs to be done and with your help quicker GPA diagnosis and even better, and less toxic, treatments will become a reality.
Revision: September 2012
The Vasculitis Foundation gratefully acknowledges Dr. Eric L. Matteson from the Mayo Clinic, Rochester, MN, for his expertise and contribution in compiling this information.