A 55-year-old man with granulomatosis with polyangiitis (GPA) achieves remission with cyclophosphamide and prednisolone. For maintenance of remission, current EULAR guidelines recommend:
- A Continue oral cyclophosphamide indefinitely
- B Switch to rituximab or azathioprine for 24 months ✓
- C High-dose prednisolone monotherapy
- D Mycophenolate mofetil as first-line maintenance
Explanation
For ANCA-associated vasculitis (GPA/MPA), cyclophosphamide is used for remission induction (3–6 months) due to its efficacy but significant cumulative toxicity (hemorrhagic cystitis, bladder malignancy, infertility, myelosuppression). Maintenance of remission should be with rituximab (preferred per RAVE and RITUXVAS trials) or azathioprine for 24 months to minimize cyclophosphamide toxicity. The MAINRITSAN trial demonstrated superiority of rituximab over azathioprine for maintenance. Mycophenolate is a second-line maintenance option; prednisolone alone is inadequate for maintenance in GPA.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.