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Eosinophilic granulomatosis with polyangiitis — SCE Respiratory MCQ

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HardBiologicsEosinophilic granulomatosis with polyangiitisSCE Respiratory

A 58-year-old man has biopsy-confirmed eosinophilic granulomatosis with polyangiitis (EGPA), initially presenting with adult-onset eosinophilic asthma, chronic rhinosinusitis with nasal polyposis, pulmonary infiltrates and mononeuritis multiplex. Remission was induced with glucocorticoids and cyclophosphamide, followed by azathioprine maintenance. During the subsequent 14 months, he has had two relapses while prednisolone was tapered below 12.5 mg daily. Each comprised worsening asthma, sinus disease, migratory pulmonary infiltrates and recurrent blood eosinophilia, and responded to an increase in prednisolone. He now takes prednisolone 15 mg daily and azathioprine at a tolerated therapeutic dose. He has residual stable foot drop but no new neuropathy. Urinalysis is bland, renal function and troponin are normal, and echocardiography shows no cardiac involvement. His BVAS is 6. He is sensitised to house-dust mite, with a total IgE of 240 IU/mL. The vasculitis multidisciplinary team classifies his disease as relapsing EGPA without current organ-threatening or life-threatening manifestations and proposes an add-on biologic. Which regimen and planned response assessment most closely follow current NICE guidance in England?

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Correct answer: E — Initiate benralizumab 30 mg subcutaneously every 4 weeks; at 52 weeks require BVAS 0 plus either a corticosteroid reduction of at least 50% or a dose of 7.5 mg daily or less

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

This patient has relapsing EGPA despite glucocorticoid and immunosuppressant therapy, but no current organ-threatening or life-threatening manifestation. NICE recommends benralizumab as an add-on to standard care for adults with relapsing or refractory EGPA. The EGPA regimen is 30 mg subcutaneously every 4 weeks, unlike the severe-asthma regimen, which changes to every 8 weeks after the first three doses. At 52 weeks, continuation requires both BVAS 0 and an oral corticosteroid reduction of at least 50% from baseline or to 7.5 mg daily or less. A is inappropriate for the current predominantly eosinophilic, non-organ-threatening relapse; rituximab would be more compelling for active organ-threatening vasculitic disease. B is attracted by his allergic asthma phenotype, but omalizumab would treat allergic asthma rather than the multisystem EGPA driving steroid dependence. C uses the licensed EGPA dose of mepolizumab and is clinically plausible, but NICE terminated its EGPA appraisal without a recommendation because no evidence submission was provided; benralizumab now has directly applicable NICE guidance. D incorrectly imports the benralizumab maintenance schedule for severe eosinophilic asthma. Previous severe disease does not itself exclude benralizumab once the organ-threatening episode has been stabilised.

Reference: Benralizumab for treating relapsing or refractory eosinophilic granulomatosis with polyangiitis — Recommendations (3 September 2025) — https://www.nice.org.uk/guidance/ta1096/chapter/1-Recommendations Fasenra 30 mg solution for injection in pre-filled pen — Summary of Product Characteristics (4 August 2026) — https://www.medicines.org.uk/emc/product/10559/smpc Benralizumab for treating relapsing or refractory eosinophilic granulomatosis with polyangiitis — Committee discussion (3 September 2025) — https://www.nice.org.uk/guidance/ta1096/chapter/3-Committee-discussion