Mepolizumab Therapy in Eosinophilic Granulomatosis with Polyangiitis: 1-Year Follow-Up Study Using Anti-IL-5 as a Steroid Sparing Therapeutic Approach - European Medical Journal
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Mepolizumab Therapy in Eosinophilic Granulomatosis with Polyangiitis: 1-Year Follow-Up Study Using Anti-IL-5 as a Steroid Sparing Therapeutic Approach

| Nephrology
Authors:
*Allyson Egan,1 Pasupathy Sivasothy,1 Robin Gore,3 Caroline Owen,3 Marcos Del Martinez Pero,,4 Rachel Jones,1 Rona Smith,1 Lisa Willcocks,1 Stella Burns,1 David R.W. Jayne2
Disclosure:

Mrs Owen reports lecture fees from GlaxoSmithKline (GSK), outside the submitted work. Prof Jayne reports personal fees from AstraZeneca and grants and personal fees from GSK, outside the submitted work. Dr Jones reports research grant funding from GSK and consultancy fees from Chemocentryx, outside the submitted work. The other authors have declared no conflicts of interest.

Citation
EMJ Nephrol. ;8[1]:34-37. Abstract Review No: AR3.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a small vessel vasculitis characterised by the presence of tissue eosinophilia, necrotising vasculitis, and granulomatous inflammation.1 Typically, a prodromal asthmatic phase, leads to an eosinophilic stage, which can evolve to include the presence of vasculitis with renal manifestations.2,3 In the recent randomised, placebo-controlled MIRRA trial for relapsing and refractory EGPA, adjuvant therapy with the anti-IL-5 monoclonal antibody, mepolizumab (MEPO), at 300 mg subcutaneously (SC) monthly, resulted in a longer remission period, reduced steroid exposure, and reduced relapse rates.4,5

AIMS

The aim of this study was to analyse the response and outcome for EGPA patients who received MEPO monthly for a minimum of 52 weeks, with particular focus on the steroid minimisation benefits. This retrospective, descriptive study analysed 13 EGPA patients, who received 100 mg SC monthly MEPO therapy under the eosinophilic asthma care pathway. Time points of assessment included MEPO commencement (M0) and 12 months (M12).

RESULTS

This study demonstrated that anti-IL-5 therapy serves as a favourable model with steroid minimisation, improvement in the Asthma Control Questionnaire (ACQ), reduction in the Birmingham Vasculitis Activity Score (BVAS) and eosinophil counts at 100 mg SC dosage (Table 1). Anti-neutrophil cytoplasm antibody positive serology normalised in all four patients, independent of subtype. MEPO was well tolerated, and demonstrated considerable clinical benefit, with 12 patients (92.3%) continuing anti-IL-5 therapy beyond 12 months.6,7 One patient had MEPO switched to rituximab to treat both EGPA and new onset rheumatoid arthritis. Adjuvant therapy with conventional immunosuppressants was well tolerated and renal function was preserved.

Table 1: Eosinophilic granulomatosis with polyangiitis patients receiving mepolizumab therapy for 1 year (100 mg subcutaneously).

ACQ: Asthma Control Questionnaire; ANCA: Anti-neutrophil cytoplasm antibodies; BVAS: Birmingham Vasculitis Activity Score; EGPA: eosinophilic granulomatosis with polyangiitis; F: female; IQR: interquartile range; IVIG: intravenous immunoglobulin; M: male; MMF: mycophenolate mofetil, MTX: methotrexate; SD: standard deviation.

CONCLUSION

The relapsing nature of EGPA places a potential dependency of therapy on steroids for asthmatic and vasculitic flares.8 This underscores the importance of pathway targeted biologic therapy to minimise steroid exposure, prevent tissue damage accrual, and ensure early response to treatment.9,10

References
Jennette J et al. 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. 2013;65(1):1-11. Gauckler P et al. Eosinophilia and kidney disease: more than just an incidental finding? J Clin Med. 2018;7(12):529. Lyons P et al. Genome-wide association study of eosinophilic granulomatosis with polyangiitis reveals genomic loci stratified by ANCA status. Nat Commun. 2019;5120:1-13. Wechsler M et al. Mepolizumab or placebo for eosinophilic granulomatosis with Polyangiitis. N Engl J Med. 2017;376(20):1921-32. Steinfeld J et al. Evaluation of clinical benefit from treatment with mepolizumab for patients with eosinophilic granulomatosis with polyangiitis. J Allergy Clin Immunol. 2019;143(6):2170-7. Khatri S et al. Assessment of the long-term safety of mepolizumab and durability of clinical response in patients with severe eosinophilic asthma. J Allergy Clin Immunol. 2019;143(5):1742-51.e7. Pradhan R et al. Safety and efficacy of mepolizumab in patients with eosinophilic granulomatosis with polyangiitis. Pulm Med. 2019;2019:4376380. Groh M et al. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (EGPA) Consensus Task Force recommendations for evaluation and management. Eur J Intern Med. 2015;26(7):545-53. Mohammad A et al. Rituximab for the treatment of eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Ann Rheum Dis. 2016;75(2):396-401. Teixeira V et al. Efficacy and safety of rituximab in the treatment of eosinophilic granulomatosis with polyangiitis. RMD Open. 2019;5(1):1-8.