A 55-year-old man has 3 weeks of fever, weight loss, sinusitis, haemoptysis, and haematuria. c-ANCA/PR3-ANCA is positive. Renal biopsy shows pauci-immune crescentic glomerulonephritis. Per current EULAR guidelines, which induction regimen is preferred for severe ANCA-associated vasculitis?
- A Cyclophosphamide plus glucocorticoids (standard regimen)
- B Rituximab plus glucocorticoids (RAVE/RITUXVAS evidence)
- C Either cyclophosphamide or rituximab plus glucocorticoids — both are recommended ✓
- D Mycophenolate mofetil plus glucocorticoids
Explanation
Current EULAR 2022 guidelines recommend either rituximab (375 mg/m² weekly × 4 doses) or cyclophosphamide combined with high-dose glucocorticoids as equivalent first-line induction for severe ANCA-associated vasculitis (GPA or MPA). This is based on the RAVE trial (rituximab non-inferior to cyclophosphamide for induction) and RITUXVAS trial. Rituximab is preferred in relapsing disease, young patients wanting fertility preservation, or when cyclophosphamide toxicity is a concern. Mycophenolate is inferior for induction in severe disease but acceptable for non-organ-threatening disease.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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