Might maintenance therapy be discontinued once clinical remission is achieved in ANCA-associated vasculitis?

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) encompasses a group of rare, multisystem autoimmune disorders characterised by the occurrence of inflammation and damage to small blood vessels, leading to a wide range of clinical manifestations. They include granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Outcomes for patients with MPA and GPA have been transformed over recent years. However, the establishment of effective maintenance therapy aiming to balance the risks of disease relapse with those related to prolonged immunosuppression has become a clinical priority. This review aims to explore two differing perspectives on this unsolved problem. Pros and Cons of the following approaches will be discussed: “Biomarker-guided personalised approach on top of generic maintenance strategy guidelines” or “ANCA specificity-related personalised maintenance treatment after intensive B-cell depletion”? • In managing AAV, it’s crucial to balance controlling the disease with avoiding treatment-related side effects. • Stratifying patients by ANCA status, B-cell repopulation and new biomarkers can help identify those at higher relapse risk. • Intensive induction regimens like the IBCD protocol have shown rapid remission induction and longer disease-free survival. • Achieving negative ANCA status following induction therapy is of utmost importance for patient's subsequent outcome. • Growing evidence suggests that, at least in MPO-AAV, maintenance may not be required, especially after an IBCD regimen.