ANCA vasculitis induction — SCE Rheumatology MCQ

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HardRheumatological pharmacologyANCA vasculitis inductionSCE Rheumatology

A 52-year-old man with PR3-ANCA-positive granulomatosis with polyangiitis previously achieved remission after intravenous cyclophosphamide and glucocorticoids and has been receiving azathioprine maintenance therapy. He now develops a major relapse with diffuse alveolar haemorrhage, active urinary sediment and a serum creatinine of 280 micromol/L. Which drug is preferred as the principal remission-induction immunosuppressive agent, in addition to an appropriate glucocorticoid regimen?

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Correct answer: A — Rituximab

Rituximab is preferred for remission induction in active relapsing granulomatosis with polyangiitis, particularly with PR3-ANCA positivity, and should be combined with an appropriate glucocorticoid regimen. The pulmonary haemorrhage and glomerulonephritis establish organ-threatening relapse. Cyclophosphamide is an effective alternative for organ-threatening GPA/MPA, but current BSR guidance favours rituximab in relapsing disease, making it the single best answer. Avacopan may be incorporated to reduce glucocorticoid exposure but does not replace rituximab or cyclophosphamide as the principal induction immunosuppressant. Mycophenolate mofetil is not preferred for organ-threatening disease because of less reliable disease control and relapse concerns. Mepolizumab is used principally for relapsing or refractory eosinophilic granulomatosis with polyangiitis, not PR3-ANCA-positive GPA.

Reference: British Society for Rheumatology, The 2025 British Society for Rheumatology management recommendations for ANCA-associated vasculitis, GPA/MPA treatment recommendations and algorithm, 2025. https://pubmed.ncbi.nlm.nih.gov/40499922/