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Eosinophilic Granulomatosis With Polyangiitis: Newer Therapies

  • Vasculitis (L Espinoza, Section Editor)
  • Published:
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Abstract

Purpose of review

Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic disseminated vasculitis associated with extravascular granulomas in patients suffering from asthma and tissue eosinophilia. Current therapies to achieve remission and prevent relapse include glucocorticoids and immunosuppressants like cyclophosphamide.

Recent findings

With the right treatment, clinical prognosis is favorable, so concerted efforts have been made in recent years to find new alternatives for treating severe EGPA. Monoclonal antibodies such as omalizumab, rituximab, and mepolizumab are among these new options.

Summary

This review summarizes the pathogenesis and clinical manifestations of EGPA and critically examines current and emerging therapies.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Guillevin L, Hagen EC, Hoffman GS, Jayne DR, Kallenberg CGM, Lamprecht P. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65:1–11. The current consensus is achieved to describe clinical, radiological, and histological aspects useful in daily practice.

    PubMed  Google Scholar 

  2. Sinico RA, Di Toma L, Maggiore U, Bottero P, Radice A, Tosoni C, et al. Prevalence and clinical significance of antineutrophil cytoplasmic antibodies in Churg-Strauss syndrome. Arthritis Rheum. 2005;52:2926–35.

    Article  CAS  PubMed  Google Scholar 

  3. Valent P, Klion AD, Horny H, Roufosse F, Gotlib J. Contemporary consensus proposal on criteria and classification of eosinophilic disorders and related syndromes. J Allergy Clin Immunol. 2012;130:607–12.e9.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Watts RA, Lane S. What is known about the epidemiology of the vasculitides? Best Pract Res Clin Rheumatol. 2005;19:191–207.

    Article  PubMed  Google Scholar 

  5. Vaglio A, Buzio C, Zwerina J. Eosinophilic granulomatosis with polyangiitis (Churg–Strauss): state of the art. Allergy. 2013;68:261–73.

    Article  CAS  PubMed  Google Scholar 

  6. Churg J, Strauss L. Allergic granulomatosis, allergic angiitis, and periarteritis nodosa. Am J Pathol. 1951;27:277–301.

    CAS  PubMed  PubMed Central  Google Scholar 

  7. Somer T, Finefold SM. Vasculitides associated with infections, immunization, and antimicrobial drugs. Clin Infect Dis. 1995;20:1010–36.

    Article  CAS  PubMed  Google Scholar 

  8. Vaglio A, Martorana D, Maggiore U, Grasselli C, Zanetti A, Pesci A, et al. HLA–DRB4 as a genetic risk factor for Churg–Strauss syndrome. Arthritis Rheum. 2007;56:3159–66.

    Article  CAS  PubMed  Google Scholar 

  9. Jakiela B, Sanak M, Szczeklik W, Sokolowska B, Plutecka H, Mastalerz L, et al. Both Th2 and Th17 responses are involved in the pathogenesis of Churg–Strauss syndrome. Clin Exp Rheumatol. 2011;29:S23–34.

    PubMed  Google Scholar 

  10. Schneeweis C, Rafalowicz M, Feist E, Buttgereit F, Rudolph PE, Burmester GR, et al. Increased levels of BLyS and sVCAM-1 in anti-neutrophil cytoplasmatic antibody (ANCA)-associated vasculitides (AAV). Clin Exp Rheumatol. 2010;28:62–6.

    PubMed  Google Scholar 

  11. Mouthon L, Dunoque B, Guillevin L. Diagnosis and classification of eosinophilic granulomatosis with polyangiitis (formerly named Churg-Strauss syndrome). J Autoimmun. 2014;48-49:99–103.

    Article  CAS  PubMed  Google Scholar 

  12. • Jakiela B, Szczeklik W, Plutecka H, Sokolowska B, Mastalerz L, Sanak M, et al. Increased production of IL-5 and dominant Th2-type response in airways of Churg-Strauss syndrome patients. Rheumatology (Oxford). 2012;51:1887–93. This paper demonstrates the role of Th2 and Il5 in the pathogenesis of EGPA.

    Article  CAS  Google Scholar 

  13. •• Jennette JC, Falk RJ, Andrassy K, Bacon PA, Churg J, Gross WL, et al. Nomenclature of systemic vasculitides: proposal of an international consensus conference. Arthritis Rheum. 1994;37:187–92. Describes the consensus of the Chapel Hill nomenclature for systemic vasculitis.

    Article  CAS  PubMed  Google Scholar 

  14. Lhote F, Guillevin L. Polyarteritis nodosa, microscopic polyangiitis, and Churg–Strauss syndrome. Clinical aspects and treatment. Rheum Dis Clin N Am. 1995;21:911–47.

    CAS  Google Scholar 

  15. Greco A, Rizzo MI, De Virgilio A, Gallo A, Fusconi M, Ruoppolo G, et al. Churg-Strauss syndrome. Autoimmun Rev. 2015;14:341–8.

    Article  CAS  PubMed  Google Scholar 

  16. Lanham JG, Elkon KB, Pusey CD, Hughes GR. Systemic vasculitis with asthma and eosinophilia: a clinical approach to the Churg–Strauss syndrome. Medicine (Baltimore). 1984;63:65–81.

    Article  CAS  Google Scholar 

  17. Masi AT, Hunder GG, Lie JT, Michel BA, Bloch DA, Arend WP, et al. The American College of Rheumatology 1990 criteria for the classification of Churg–Strauss syndrome (allergic granulomatosis and angiitis). Arthritis Rheum. 1990;33:1094–100.

    Article  CAS  PubMed  Google Scholar 

  18. Mukhtyar C, Flossmann O, Hellmich B, Bacon P, Cid M, Cohen-Tervaert JW, et al. Outcomes from studies of antineutrophil cytoplasm antibody associated vasculitis: a systematic review by the European League Against Rheumatism Systemic Vasculitis Task Force. Ann Rheum Dis. 2008;67:1004–10.

    Article  CAS  PubMed  Google Scholar 

  19. Guillevin L, Lhote F, Gayraud M, Cohen P, Jarrousse B, Lortholary O, et al. Prognostic factors in polyarteritis nodosa and Churg–Strauss Syndrome. A prospective study in 342 patients. Medicine (Baltimore). 1996;75:17–28.

    Article  CAS  Google Scholar 

  20. Groh M, Pagnoux C, Baldini C, Bel E, Bottero P, Cottin V, et al. Eosinophilic granulomatosis with polyangiitis (Churg–Strauss) (EGPA) Consensus Task Force recommendations for evaluation and management. Eur J Intern Med. 2015;26:545–53.

    Article  PubMed  Google Scholar 

  21. Pagnoux C, Guilpain P, Guillevin L. Churg–Strauss syndrome. Curr Opin Rheumatol. 2007;19:25–32.

    Article  PubMed  Google Scholar 

  22. Samson M, Puéchal X, Devilliers H, Ribi C, Cohen P, Stern M, et al. Long-term outcomes of 118 patients with eosinophilic granulomatosis with polyangiitis (Churg–Strauss syndrome) enrolled in two prospective trials. J Autoimmun. 2013;43:60–9.

    Article  PubMed  Google Scholar 

  23. De Groot K, Harper L, Jayne DR, Flores Suarez LF, Gregorini G, Gross WL, et al. Pulse versus daily oral cyclophosphamide for induction of remission in antineutrophil cytoplasmic antibody-associated vasculitis. Ann Intern Med. 2009;150:670–80.

    Article  PubMed  Google Scholar 

  24. Pagnoux C, Quéméneur T, Ninet J, Perrodeau E, Diot E, Kyndt X, et al. Treatment of systemic necrotizing vasculitides in patients aged sixty-five years or older: results of a multicenter, open-label, randomized controlled trial of corticosteroid and cyclophosphamide-based induction therapy. Arthritis Rheumatol. 2015;67:1117–27.

    Article  CAS  PubMed  Google Scholar 

  25. Jayne D, Rasmussen N, Andrassy K, Bacon P, Tervaert JW, Dadoniené J, et al. Randomized trial of maintenance therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies. N Engl J Med. 2003;349:36–44.

    Article  CAS  PubMed  Google Scholar 

  26. Pagnoux C, Mahr A, Hamidou MA, Boffa JJ, Ruivard M, Ducroix JP, et al. Azathioprine or methotrexate maintenance for ANCA-associated vasculitis. N Engl J Med. 2008;359:2790–803.

    Article  CAS  PubMed  Google Scholar 

  27. Guillevin L, Pagnoux C, Karras A, Khouatra C, Aumaître O, Cohen P, et al. Rituximab versus azathioprine for maintenance in ANCA-associated vasculitis. N Engl J Med. 2014;371:1771–80.

    Article  PubMed  Google Scholar 

  28. Puéchal X, Pagnoux C, Baron G, French Vasculitis Study Group, et al. Adding azathioprine to remission-induction glucocorticoids for eosinophilic granulomatosis with polyangiitis (Churg-Strauss), microscopic polyangiitis, or polyarteritis nodosa without poor prognosis factors: a randomized, controlled trial. Arthritis Rheumatol. 2017;69:2175–86.

    Article  PubMed  Google Scholar 

  29. •• Yates M, Watts R, Bajema I, Cid M, Crestani B, Hauser T, et al. Validation of the EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis by disease content experts. RMD Open. 2017;3:e000449. This paper makes the EULAR/ERA-EDTA treatment focus recommendations for EGPA patients based on level evidence.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Danieli MG, Cappelli M, Malcangi G, Logullo F, Salvi A, Danieli G. Long term effectiveness of intravenous immunoglobulin in Churg–Strauss syndrome. Ann Rheum Dis. 2004;63:1649–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Jones RB, Tervaert JW, Hauser T, Luqmani R, Morgan MD, Peh CA, et al. Rituximab versus cyclophosphamide in ANCA associated renal vasculitis. N Engl J Med. 2010;363:211–20.

    Article  CAS  PubMed  Google Scholar 

  32. Stone JH, Merkel PA, Spiera R, Seo P, Langford CA, Hoffman GS, et al. Rituximab versus cyclophosphamide for ANCA associated vasculitis. N Engl J Med. 2010;363:221–32.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Specks U, Merkel PA, Seo P, Spiera R, Langford CA, Hoffman GS, et al. Efficacy of remission-induction regimens for ANCA associated vasculitis. N Engl J Med. 2013;369:417–27.

    Article  CAS  PubMed  Google Scholar 

  34. Thiel J, Hässler F, Salzer U, Voll RE, Venhoff N. Rituximab in the treatment of refractory or relapsing eosinophilic granulomatosis with polyangiitis (Churg−Strauss syndrome). Arthritis Res Ther. 2013;15:R133.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Thiel J, Troilo A, Salzer U, Schleyer T, Halmschlag K, Rizzi M. Rituximab as induction therapy in eosinophilic granulomatosis with polyangiitis refractory to conventional immunosuppressive treatment: a 36-month follow-up analysis. J Allergy Clin Immunol Pract. 2017;5:1555–63.

    Article  Google Scholar 

  36. Mohamad AJ, Hot A, Arndt F, Moosiq F, Guerry MJ, Amudala N, et al. Rituximab for the treatment of eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Ann Rheum Dis. 2016;75:396–401.

    Article  Google Scholar 

  37. Aguirre- Valencia D, Posso-Osorio I, Bravo JC, Bonilla- Abadía F, Tobón GJ, Cañas CA. Sequential rituximab and omalizumab for the treatment of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Clin Rheumatol. 2017;36:2159–62.

    Article  PubMed  Google Scholar 

  38. Noga O, Hanf G, Brachmann I, Klucken AC, Kleine-Tebbe J, Rosseau S, et al. Effect of omalizumab treatment on peripheral eosinophil and T-lymphocyte function in patients with allergic asthma. J Allergy Clin Immunol. 2006;117:1493–9.

    Article  CAS  PubMed  Google Scholar 

  39. Giavina-Bianchi P, Giavina-Bianchi M, Agondi R, Kalil J. Administration of anti-IgE to a Churg-Strauss syndrome patient. Int Arch Allergy Immunol. 2007;144:155–8.

    Article  PubMed  Google Scholar 

  40. Detoraki A, Di Capua L, Varricchi G, Genovese A, Marone G, Spadaro G. Omalizumab in patients with eosinophilic granulomatosis with polyangiitis: a 36-month follow-up study. J Asthma. 2016;53:201–6.

    Article  CAS  PubMed  Google Scholar 

  41. • Jachiet M, Samson M, Cottin M, Kahn JE, Le Guenno G, Bonniaud P, et al. Anti-IgE monoclonal antibody (omalizumab) in refractory and relapsing eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Arthritis Rheumatol. 2016;68:2274–82. This is the largest study which used omalizumab in EGPA patients.

    Article  CAS  PubMed  Google Scholar 

  42. Nazir S, Tachamo N, Fareedy SB, Khan MS, Lohani S. Omalizumab-associated eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Ann Allergy Asthma Immunol. 2017;118:372–4.e1.

    Article  PubMed  Google Scholar 

  43. Bekçibaşı M, Barutçu S, Çelen MK, Dayan S, Hoşoğlu S. Churg-Strauss syndrome occurring during omalizumab treatment. Eur J Rheumatol. 2015;2:129–30.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Cisneros C, Segrelles G, Herráez L, Gonzalez A, Girón R. Churg-Strauss syndrome in a patient treated with omalizumab. J Investig Allergol Clin Immunol. 2013;23:515–6.

    CAS  PubMed  Google Scholar 

  45. Wechsler ME, Wong DA, Miller MK, Lawrence-Miyasaki L. Churg-Strauss syndrome in patients treated with omalizumab. Chest. 2009;136:507–18.

    Article  PubMed  Google Scholar 

  46. Puéchal X, Rivereau P, Vinchon F. Churg-Strauss syndrome associated with omalizumab. Eur J Intern Med. 2008;19:364–6.

    Article  PubMed  Google Scholar 

  47. Gauvreau GM, Boulet LP, Leigh R, Cockcroft DW, Davis BE, Mayers I. QGE031 (ligelizumab) is more effective than omalizumab and placebo in inhibiting allergen-induced early asthmatic response: results from a predictive modeling study. Eur Respir J. 2015;46:PA5091.

    Article  Google Scholar 

  48. Bagnasco D, Ferrando M, Varricchhi G, Puggioni F, Passalacqua G, Canonica GW. Anti-interleukin 5 (iL-5) and iL-5Ra biological drugs: efficacy, safety, and future perspectives in severe eosinophilic asthma. Front Med (Lausanne). 2017;4:135.

    Article  Google Scholar 

  49. Kahn JE, Grandpeix-Guyodo C, Marroun I, Catherinot E, Mellot F, Roufosse F, et al. Sustained response to mepolizumab in refractory Churg-Strauss syndrome. J Allergy Clin Immunol. 2010;125:267–70.

    Article  CAS  PubMed  Google Scholar 

  50. Kim S, Marigowda G, Oren E, Israel E, Wechsler ME. Mepolizumab as a steroid sparing treatment option in patients with Churg–Strauss syndrome. J Allergy Clin Immunol. 2010;125:1336–43.

    Article  CAS  PubMed  Google Scholar 

  51. Moosig F, Gross WL, Herrmann K, Bremer JP, Hellmich B. Targeting interleukin-5 in refractory and relapsing Churg–Strauss syndrome. Ann Intern Med. 2011;155:341–3.

    Article  PubMed  Google Scholar 

  52. Herrmann K, Gross WL, Moosig F. Extended follow-up after stopping mepolizumab in relapsing/refractory Churg-Strauss syndrome. Clin Exp Rheumatol. 2012;30:S62–5.

    PubMed  Google Scholar 

  53. •• Wechsler ME, Akuthota P, Jayne D, Khoury P, Klion A, Langford CA, et al. Mepolizumab or placebo for eosinophilic granulomatosis with polyangiitis. N Engl J Med. 2017;376:1921–32. This is the first multicenter double-blind randomized clinical controlled trial that investigates remission in EGPA patient using mepolizumab.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Guillevin L. Vasculitis: mepolizumab for eosinophilic granulomatosis with polyangiitis. Nat Rev Rheumatol. 2017;13(9):518–9.

    Article  CAS  PubMed  Google Scholar 

  55. Beck L, Diamant T, Hamilton J, Graham N, Bieber T, Rocklin R, et al. Dupilumab in adults with moderate-to-severe atopic dermatitis. N Engl J Med. 2014;371:130–9.

    Article  PubMed  Google Scholar 

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Correspondence to Gabriel J. Tobón.

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This article is part of the Topical Collection on Vasculitis

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Navarro-Mendoza, E.P., Tobón, G.J. Eosinophilic Granulomatosis With Polyangiitis: Newer Therapies. Curr Rheumatol Rep 20, 23 (2018). https://doi.org/10.1007/s11926-018-0736-2

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