title: A randomized trial of maintenance therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies.
abstract: BACKGROUND
  The primary systemic vasculitides usually associated with autoantibodies to neutrophil cytoplasmic antigens include Wegener's granulomatosis and microscopic polyangiitis. We investigated whether exposure to cyclophosphamide in patients with generalized vasculitis could be reduced by substitution of azathioprine at remission.
  
  
  METHODS
  We studied patients with a new diagnosis of generalized vasculitis and a serum creatinine concentration of 5.7 mg per deciliter (500 micromol per liter) or less. All patients received at least three months of therapy with oral cyclophosphamide and prednisolone. After remission, patients were randomly assigned to continued cyclophosphamide therapy (1.5 mg per kilogram of body weight per day) or a substitute regimen of azathioprine (2 mg per kilogram per day). Both groups continued to receive prednisolone and were followed for 18 months from study entry. Relapse was the primary end point.
  
  
  RESULTS
  Of 155 patients studied, 144 (93 percent) entered remission and were randomly assigned to azathioprine (71 patients) or continued cyclophosphamide (73 patients). There were eight deaths (5 percent), seven of them during the first three months. Eleven relapses occurred in the azathioprine group (15.5 percent), and 10 occurred in the cyclophosphamide group (13.7 percent, P=0.65). Severe adverse events occurred in 15 patients during the induction phase (10 percent), in 8 patients in the azathioprine group during the remission phase (11 percent), and in 7 patients in the cyclophosphamide group during the remission phase (10 percent, P=0.94 for the comparison between groups during the remission phase). The relapse rate was lower among the patients with microscopic polyangiitis than among those with Wegener's granulomatosis (P=0.03).
  
  
  CONCLUSIONS
  In patients with generalized vasculitis, the withdrawal of cyclophosphamide and the substitution of azathioprine after remission did not increase the rate of relapse. Thus, the duration of exposure to cyclophosphamide may be safely reduced.
authors.affiliation: Department of Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Jayne
authors.forename: Niels
authors.initials: N
authors.lastname: Rasmussen
authors.forename: Konrad
authors.initials: K
authors.lastname: Andrassy
authors.forename: Paul
authors.initials: P
authors.lastname: Bacon
authors.forename: Jan Willem Cohen
authors.initials: JW
authors.lastname: Tervaert
authors.forename: Jolanta
authors.initials: J
authors.lastname: Dadoniené
authors.forename: Agneta
authors.initials: A
authors.lastname: Ekstrand
authors.forename: Gill
authors.initials: G
authors.lastname: Gaskin
authors.forename: Gina
authors.initials: G
authors.lastname: Gregorini
authors.forename: Kirsten
authors.initials: K
authors.lastname: de Groot
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Gross
authors.forename: E Christiaan
authors.initials: EC
authors.lastname: Hagen
authors.forename: Eduardo
authors.initials: E
authors.lastname: Mirapeix
authors.forename: Erna
authors.initials: E
authors.lastname: Pettersson
authors.forename: Carl
authors.initials: C
authors.lastname: Siegert
authors.forename: Alberto
authors.initials: A
authors.lastname: Sinico
authors.forename: Vladimir
authors.initials: V
authors.lastname: Tesar
authors.forename: Kerstin
authors.initials: K
authors.lastname: Westman
authors.forename: Charles
authors.initials: C
authors.lastname: Pusey
mesh_terms: D000328:Adult; D000368:Aged; D019268:Antibodies, Antineutrophil Cytoplasmic / Q000097:blood*; D001379:Azathioprine / Q000009:adverse effects / Q000627:therapeutic use*; D003520:Cyclophosphamide / Q000009:adverse effects / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009503:Neutropenia / Q000139:chemically induced; D011239:Prednisolone / Q000627:therapeutic use; D012008:Recurrence; D012074:Remission Induction; D014657:Vasculitis / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality
chemical_list: D019268:Antibodies, Antineutrophil Cytoplasmic; D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D003520:Cyclophosphamide; D011239:Prednisolone; D001379:Azathioprine