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ANCA-associated vasculitis — SCE Acute Medicine MCQ

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HardAcute Rheumatological and Dermatological EmergenciesANCA-associated vasculitisSCE Acute Medicine

A 55-year-old man has PR3-ANCA-positive pulmonary–renal vasculitis, creatinine 310 micromol/L and diffuse alveolar haemorrhage requiring oxygen but not ventilation. Infection has been sampled and excluded as far as immediately possible. Which induction strategy is best?

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Reveal the answer and explanation

Correct answer: D — Glucocorticoid plus rituximab or cyclophosphamide; selective plasma exchange

Explanation lettering: B = shown as A · E = shown as B · A = shown as D · D = shown as E

A is correct. Organ-threatening ANCA-associated vasculitis needs prompt remission induction with glucocorticoid plus rituximab or cyclophosphamide, chosen for disease and patient factors. Plasma exchange is not routine for every pulmonary haemorrhage after PEXIVAS; consider it for selected patients with severe renal failure, dialysis dependence, rapidly rising creatinine or hypoxaemic diffuse alveolar haemorrhage after specialist risk–benefit assessment. Azathioprine is maintenance rather than acute induction, mepolizumab applies mainly to selected EGPA, and antithrombotic treatment worsens active alveolar bleeding.

Reference: https://kdigo.org/wp-content/uploads/2024/05/KDIGO-2024-ANCA-Vasculitis-Guideline-Update.pdf