Регимен LoVAS при васкулитах снижает дозу гормонов, но повышает риск ранних рецидивов

The LoVAS regimen for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) management provides very low glucocorticoid exposure, but may come at a cost of poorer disease control and more frequent early relapses, according to a study published in Rheumatology International. This single-center retrospective study from Japan compared 2 steroid-sparing regimens: the reduced-dose regimen used in the PEXIVAS trial (NCT00987389) and the very low-steroid regimen from the LoVAS trial (NCT02198248). The PEXIVAS regimen begins with high-dose therapy, usually includes intravenous methylprednisolone pulses, then tapers steroids. The LoVAS regimen uses rituximab and starts at only 0.5 mg/kg/day of prednisone without pulse methylprednisolone, resulting in a much faster taper and notably lower cumulative steroid exposure. The researchers recruited 21 patients with freshly diagnosed or relapsing microscopic polyangiitis and granulomatosis with polyangiitis. All participants received induction therapy before starting PEXIVAS (n = 16) or LoVAS (n = 5). Some PEXIVAS patients later received rituximab maintenance and/or avacopan as opposed to LoVAS patients. Relapse was the primary outcome measure. Three of 5 (60%) LoVAS patients relapsed compared to 2 of 16 (12.5%) on the PEXIVAS regimen. In most cases, relapses occurred early, on days 21, 52, and 128 after treatment initiation. Known AAV relapse risk factors, such as proteinase 3-ANCA or myeloperoxidase-ANCA positivity, relapsing disease at baseline, and variations between disease subtypes, did not explain the difference in relapse rates between the 2 groups. “One possible explanation is the difference in glucocorticoid induction strategies. The LoVAS regimen omits pulse therapy and initiates treatment with a moderate [glucocorticoid] dose followed by rapid tapering, which may reduce [glucocorticoid] exposure but could also provide less intensive early disease control in some patients. In contrast, the initial use of pulse therapy and short-term high-dose [glucocorticoids] in the PEXIVAS regimen may provide more intensive disease control during the early phase,” the study authors wrote. LoVAS patients discontinued steroids in 100% of cases compared with 5 (31%) PEXIVAS patients. There was a strong trend toward earlier steroid discontinuation in the LoVAS trial. Moreover, the average daily prednisolone-equivalent dose was 3.06 mg/day in the LoVAS group and 14.5 mg/day in the PEXIVAS group. Serious adverse events occurred in 3 LoVAS patients and 7 PEXIVAS patients. Patients on the LoVAS regimen developed a vertebral fracture, bacterial pneumonia, and biliary tract infection; those on the PEXIVAS regimen experienced a patellar fracture, COVID-19 pneumonia, urinary tract infections, a biliary tract infection, and death from pulmonary hemorrhage caused by active vasculitis. The authors emphasized that 2 LoVAS patients, who were both elderly, had low disease activity, and a Birmingham Vasculitis Activity score of 6, had satisfactory outcomes. There might be a patient population better aligned with this regimen. These findings remain hypothesis-generating rather than conclusive. The study was small and not randomized. Larger prospective studies are needed to determine which patients with AAV can safely receive the LoVAS approach. This article originally appeared on Rare Disease Advisor References: Nakamoto N, Yahata A, Oiwa H. Early relapse under the LoVAS reduced-dose glucocorticoid regimen in ANCA-associated vasculitis: a single-center retrospective observational study. Rheumatol Int. Published online June 5, 2026. doi:10.1007/s00296-026-06188-z