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EGPA relapsing asthma-eosinophilic disease — SCE Rheumatology MCQ

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HardVasculitisEGPA relapsing asthma-eosinophilic diseaseSCE Rheumatology

A 50-year-old woman with eosinophilic granulomatosis with polyangiitis is taking prednisolone and azathioprine. During the past year she has had three relapses characterised by eosinophilic asthma exacerbations and worsening chronic rhinosinusitis. Her eosinophil count is 1.2 × 10^9/L. Previous mononeuritis multiplex is unchanged and represents established damage. There is no new motor deficit, purpura, pulmonary infiltrate, renal involvement or cardiac involvement. Which biologic is the most appropriate addition to treatment?

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Correct answer: D — Mepolizumab

Mepolizumab is the best answer. This is relapsing, refractory EGPA dominated by eosinophilic asthma and sinonasal disease, without active organ- or life-threatening vasculitis. Mepolizumab targets interleukin-5 and has randomised-trial evidence for increasing remission, reducing relapse and permitting glucocorticoid reduction in this phenotype. Rituximab is more relevant when clinically important active vasculitic manifestations predominate, rather than stable neuropathic damage with isolated eosinophilic respiratory relapse. Omalizumab may treat allergic asthma but has weaker and inconsistent evidence in EGPA. Dupilumab and tezepelumab are asthma biologics without an established guideline-supported role for controlling EGPA itself. The UK-authorised EGPA dose of mepolizumab is 300 mg subcutaneously every four weeks.

Reference: European Alliance of Associations for Rheumatology. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update, EGPA recommendations, published 2023. https://www.eular.org/document/download/630/7267ef1d-6df8-46da-a4ff-3f7124f7d6a2/615