Persistent ANCA in Remission — SCE Rheumatology MCQ
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Correct answer: D — Continue structured clinical and laboratory surveillance without restarting immunosuppression solely for ANCA positivity
Explanation lettering: C = shown as A · D = shown as B · A = shown as C · E = shown as D · B = shown as E
E is correct. Persistent MPO-ANCA in an otherwise clinically quiescent patient is a relapse-risk marker, not evidence of active vasculitis by itself. EULAR recommends that treatment changes be based on structured clinical assessment rather than ANCA or B-cell results alone. Follow-up should therefore assess symptoms, examination findings, renal function and urinalysis; ANCA trends may inform the overall risk assessment but do not mandate treatment. Restarting azathioprine or rituximab solely to achieve ANCA negativity risks unnecessary immunosuppressive toxicity. Cyclophosphamide is reserved for induction of active, usually organ- or life-threatening disease, which is absent here. Conversely, ANCA is not irrelevant after remission: persistent positivity or a subsequent rise can be associated with relapse and supports continued surveillance.
Reference: Hellmich B, et al. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update, recommendation on structured clinical assessment and biomarker-guided treatment decisions. Published 2024. https://www.eular.org/document/download/630/7267ef1d-6df8-46da-a4ff-3f7124f7d6a2/615