Reconsidering Corticosteroid-First Protocols in Moderate-to-Severe Eosinophilic Granulomatosis with Polyangiitis: A Critical Appraisal of Mepolizumab-Centric Remission Induction Hierarchies
Keywords:
eosinophilic granulomatosis with polyangiitis, mepolizumab induction therapy, interleukin-5 antagonism, glucocorticoid-sparing strategies, ANCA-associated vasculitis, Birmingham Vasculitis Activity Score, eosinophilic airway inflammation, remission induction hierarchy, systemic immunosuppression protocolsAbstract
Eosinophilic granulomatosis with polyangiitis (EGPA) has historically been managed through high-dose corticosteroid induction regimens, often supplemented by cyclophosphamide in refractory cases. Emerging immunobiological evidence challenges this paradigm, particularly regarding the primacy of interleukin-5-mediated eosinophilic pathobiology in disease propagation. This study critically appraises therapeutic stratification models in 214 biopsy-confirmed EGPA patients across three tertiary referral centres (2019–2024), comparing corticosteroid-first versus mepolizumab-centric induction protocols. Outcome endpoints included Birmingham Vasculitis Activity Score normalization, glucocorticoid-sparing milestones, and peripheral eosinophil reconstitution kinetics. Mepolizumab-centric protocols demonstrated statistically superior relapse-free survival at 18 months (HR 0.41; 95% CI 0.29–0.57; p<0.001) and significantly reduced cumulative corticosteroid exposure. These findings substantiate a fundamental re-evaluation of first-line induction hierarchies in EGPA management guidelines.
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