Phase 1: Induction Therapy (The ‘Fire Extinguisher’)
When you’re first diagnosed with AAV, you may need aggressive treatment to get the illness under control.
“At the time of diagnosis, a patient often has been living for a while with persistent, ongoing, uncontrolled inflammation in small blood vessels, which is causing irreversible damage to organs such as the kidneys and lungs,” says Christopher Palma, MD, a rheumatologist and associate professor of medicine at the University of Rochester School of Medicine and Dentistry in New York.
“So when AAV is identified, we’re pulling the handle on the fire alarm and using a ‘fire extinguisher’ of treatments to try and dampen that inflammation as quickly as possible and rapidly achieve remission,” he says.
Common Induction Medications
Usually lasting three to six months, induction therapy may involve the following medications:
- High-Dose Corticosteroids Prednisone, taken orally, can quickly reduce inflammation from vasculitis. In severe cases, methylprednisone, a stronger steroid, may be given intravenously. These are almost always used in combination with another type of medication and tapered down as quickly as possible.
- Rituximab (Rituxan) This monoclonal antibody is a standard first-line treatment to bring about remission in active severe disease; it’s used in combination with corticosteroids and administered by IV infusion.
- Cyclophosphamide (Cytoxan) Cyclophosphamide is primarily a chemotherapy drug that’s in a class of medications called alkylating agents. The drug (taken orally or via IV) is another effective first-line treatment option. But it’s used less often than it was before rituximab was approved because of concerns about side effects and long-term risks.
- Benralizumab (Fasenra) The U.S. Food and Drug Administration approved this biologic drug in 2024 to treat one form of AAV called eosinophilic granulomatosis with polyangiitis (EGPA), which mainly affects your lungs. It’s a shot you give yourself under your skin.
- Mepolizumab (Nucala) Mepolizumab is also an injectable biologic that can be used to treat (EGPA).
- Methotrexate Originally a cancer drug, methotrexate (administered orally or as an injection under your skin) can be used in more mild AAV cases.
- Mycophenolate mofetil (CellCept) This oral medication can also be considered in milder disease, although some research found that the drug carries a higher risk of relapse than other induction medications.
- Avacopan (Tavenos) This is a newer medication that the FDA approved in 2021 as an add-on to standard therapy. Avacopan may replace or reduce the need for long-term corticosteroids.
What to Expect Physically
Medications for AAV are generally considered to be safe if prescribed and monitored appropriately, according to Naomi Patel, MD, a rheumatologist with Massachusetts General Hospital in Boston.
“In every case we aim to balance the risks of treatment with the benefits of disease control, and this approach has been optimized over the years,” she says. “In AAV, particularly with any organ or life-threatening manifestations, the benefits of treatment outweigh the risks associated with treatment.”
That said, you should be aware of the potential for serious side effects. For example, medications that suppress your immune system can leave you vulnerable to infections.
Prednisone, like other corticosteroids, can cause many other problems, even if you only take it for a short time. They include:
- Weight gain
- Upset stomach
- Increased blood pressure
- Mood swings
- Insomnia
- Swelling in your legs and feet
“All around, rituximab is a better treatment than prednisone with fewer side effects,” says Dr. Palma. “But it takes two to three weeks or more for rituximab to become efficacious after being administered, so steroids are a bridge before the rituximab takes effect.”
Rituximab can also cause additional side effects, most commonly:
- Infusion-related reactions
- Body aches
- Tiredness
- Nausea
Cyclophosphamide can cause nausea, vomiting, and hair loss.
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