Background/Purpose: Randomized controlled trial evidence helps guide physician treatment choices for ANCA-Associated Vasculitis (AAV). Data for remission maintenance therapy following rituximab (RTX) in generalized disease, as well as the use of RTX in limited disease, however, is currently lacking. In the absence of such data, treatment choices are largely driven by physician preferences. Our aim was to examine AAV treatment preferences to determine if patient gender and age and physician subspecialty affect treatment choices.

Methods: We invited rheumatologists, nephrologists and pulmonologists from an academic medical center to participate in a web-based survey. Three scenarios (remission induction in generalized disease; remission maintenance in generalized disease; remission induction in limited disease) were presented for 4 patient profiles (28 and 68 year old female/male). Physician treatment choices and reasons for these choices (efficacy, toxicity, cost/availability, comfort with use) were obtained. Differences between groups were analyzed using Chi-Square and Fisher’s exact tests.

Results: Of 117 surveys sent, 46 were completed by 29 rheumatologists (63%), 8 pulmonologists (17%) and 9 nephrologists (19%).

For remission induction in generalized disease, 52% of physicians selected RTX, 42% CTX, 3% mycophenolate mofetil, and 3% no preference. Physicians were significantly more likely to choose RTX for young females compared with young males (p=0.039), older males (p<0.001), and older females (p<0.001). Toxicity was the most common reason for this choice. There was a trend toward rheumatologists choosing RTX over CTX compared with the other subspecialties.

Most physicians switched to a less toxic agent for remission maintenance (Table 1), but there was little agreement as to choice of maintenance therapy among subspecialties. It did appear, however, that pulmonologists were significantly less likely to choose azathioprine (AZA) (p=0.002) and nephrologists methotrexate (MTX) (p=0.007) than the other subspecialties.

For remission induction in limited disease, most chose RTX (36%), particularly for young females, followed by CTX (26%), MTX (24%), AZA (6%), trimethoprim/sulfamethoxazole (4%) and 4% no preference. Efficacy was the most common reason for selecting RTX. Rheumatologists chose RTX (34%) and MTX (31%) about equally, whereas pulmonologists chose RTX (67%) and nephrologists chose CTX (40%) most often.

Conclusion: Most physicians favor RTX for remission induction in young females with generalized disease because of toxicity issues, with a trend toward rheumatologists prescribing RTX more frequently than other subspecialties in this setting. Surprisingly, most physicians preferred RTX for remission induction even for limited disease, despite lack of clinical trial data supporting its use in this context. There was less agreement as to choice of remission maintenance therapy among subspecialties.