Medication adherence and real-world factors of first line induction treatment selection in ANCA-associated vasculitis

Pınar Akyüz Dağlı; Esra Kayacan  Erdoğan; Hatice Ecem  Konak; Bahar Özdemir Ulusoy; Serdar Can Güven; Berkan Armağan; Rezan Koçak Ulucaköy; Kevser Orhan; Ebru Atalar; İsmail Doğan; Yüksel Maraş; Ahmet Omma; Orhan Küçükşahin; Şükran Erten; Hakan Babaoğlu

doi:10.36141/svdld.v42i4.16880

Authors

Pınar Akyüz Dağlı Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey https://orcid.org/0000-0002-4249-8818
Esra Kayacan Erdoğan Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey https://orcid.org/0000-0002-3570-875X
Hatice Ecem Konak Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey https://orcid.org/0000-0002-9218-8965
Bahar Özdemir Ulusoy Ankara Gaziler Physical Therapy and Rehabilitation Training and Research Hospital, Department of Rheumatology, Ankara, Turkey https://orcid.org/0000-0003-4711-4921
Serdar Can Güven Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey https://orcid.org/0000-0003-1965-9756
Berkan Armağan Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey https://orcid.org/0000-0003-4409-059X
Rezan Koçak Ulucaköy Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey
Kevser Orhan Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey https://orcid.org/0000-0001-8639-751X
Ebru Atalar Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey https://orcid.org/0000-0003-2708-0373
İsmail Doğan Department of Internal Medicine, Division of Rheumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey https://orcid.org/0000-0002-7603-9484
Yüksel Maraş Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, University of Health Sciences, Ankara, Turkey https://orcid.org/0000-0001-9319-0955
Ahmet Omma Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, University of Health Sciences, Ankara, Turkey https://orcid.org/0000-0003-2582-7445
Orhan Küçükşahin Department of Internal Medicine, Division of Rheumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey https://orcid.org/0000-0003-4530-2304
Şükran Erten Department of Internal Medicine, Division of Rheumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey https://orcid.org/0000-0003-0717-8365
Hakan Babaoğlu Department of Internal Medicine, Division of Rheumatology, Ankara Bilkent City Hospital, Ankara, Turkey

Keywords:

ANCA-associated vasculitis; remission induction; remission maintenance; treatment adherence; treatment choices; cyclophosphamide; rituximab.

Abstract

Background & Objective:
This study aimed to explore real-world factors that may influence the selection of first-line remission-induction therapy in ANCA-associated vasculitis(AAV), as well as to evaluate physician compliance with guideline recommendations and patient adherence to maintenance therapies.

Methods:
A retrospective analysis of 112 patients with AAV, including granulomatosis with polyangiitis(GPA, 67%), microscopic polyangiitis(MPA, 13%),and eosinophilic granulomatosis with polyangiitis (EGPA, 20%), was conducted at a single tertiary care center using electronic health records from 2018 to 2023. Treatment regimens, patient demographics, organ involvement, and adherence to EULAR guidelines were analyzed.Patients receiving RTX or CYC as first-line remission-induction therapy were compared.Compliance was defined as alignment with guideline-recommended dosing and timing of induction therapy, while adherence during maintenance was evaluated based on consistency with prescribed regimens, assessed via prescription refill data.

Results:

Of the 102 patients included in the study, 85 received CYC and 17 received RTX as first-line remission induction therapy.Compared to the RTX group, those receiving CYC were significantly older (median age 57 vs. 44 years, p <0.05), had higher BVAS scores (median 12 vs. 10, p = 0.02), and exhibited more comorbidities (74% vs. 35%). Organ involvement rates were similar in both groups. No significant differences in major organ involvement were observed between the two groups. RTX adherence was 100% in both the induction and maintenance phases, whereas adherence to oral maintenance therapies was notably lower, at 66% for methotrexate, 36% for mycophenolate mofetil, and 28% for azathioprine.

Conclusion:
In real-world practice, older age, higher BVAS, and a greater comorbidity burden appear to influence clinicians’ preference for CYC over RTX as first-line induction,despite similar organ involvement between groups.Overall compliance with induction guidelines was high,but adherence to oral maintenance regimens remained suboptimal.These findings underscore the need for personalized treatment strategies and targeted measures to enhance long-term medication adherence in AAV.

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