Getting the balance right: adverse events of therapy in anti-neutrophil cytoplasm antibody vasculitis

Antineutrophil cytoplasm antibody associated systemic vasculitides (AASV) have traditionally been managed with a combination of cyclophosphamide and glucocorticoids during the induction phase, followed by azathioprine in the maintenance phase. Whilst these therapies have markedly improved the prognosis in AASV, treatment related adverse events remain a major challenge and include complications such as infection, glucocorticoid related side effects, malignancy, cardiovascular disease, infertility and death. Newer biologic therapies have been shown to demonstrate equivalent efficacy as cyclophosphamide for remission but the hoped for reduction in adverse events has yet to be realised. More recent efforts have been focused on refining existing therapeutic regimens and strategies, tailoring individual treatment to disease severity, patient age and kidney function to derive maximum treatment efficacy while minimising treatment toxicity. In particular, current interventional trials are targeting a reduction in corticosteroid exposure in an effort to make induction and maintenance regimens safer.