Introduction: The purpose of this proposal is to improve the treatment of a group of rare, multisystem diseases in order to save lives and improve the quality of life for survivors. This can only be achieved by performing randomised clinical trials (RCTs) on a multinational basis.
Background: Anti-neutrophll cytoplasm autoantibody (ANCA)-associated systemic vasculitis (AASV) is a group of severe, multisystem, autoimmune diseases (e. g. Wegener's granulomatosis and microscopic polyangiitis), which cause marked incapacity and chronic morbidity due to irreversible organ damage, such as renal failure. The incidence of AASV is increasing, especially in the elderly, and exceeds 25/million/year. Care outside specialist centres is often fragmented and treatment suboptimal. The toxicity of current treatments contributes to incapacity through high cumulative exposure to steroid and cytotoxic drugs. This proposal will improve the efflcacy of treatment, reduce disease-induced damage and minimise drug toxicity.
Methods: Four RCTs will test new therapeutic approaches, already piloted in single centres, and are targeted at patient subgroups, covering the entire spectrum of the diseases. They will aim at: ù improving disease control with intravenous immunoglobulin or sulfamethoxazole/ trimethoprim in addition to standard treatment ù lowering cyclophosphamide toxicity by replacing continuous oral treatment with pulsed intravenous administration ù reducing relapse rate by elimination of nasal carriage of Staphylococcus aureus ù reducing relapse rate by long-term, low dose azathioprine treatment in place of treatment withdrawal The RCTs will utilise innovative statistical techniques and trial methodology.
Prognostic markers and surrogate end-points will be defined to optimise clinical decision making by identifying patient subgroups and will contribute to the design of a further series of RCTs to test new drugs currently in pilot studies.
The network and its benefits: Prevlous European, multi-disciplinary collaboration has standardised ANCA assays and diagnostic criteria (EC/BCR, 7 centres 1990-1994) and has designed scoring tools and harmonised treatment through a series of RCTs comparing existing regimens (BIOMED 1, ECSYSVASTRIAL, 18 centres 1994, 90 centres in 15 countries 1996). Increasing participation has maximised the dissemination of the results obtained to routine clinical practice. Industrial collaboration for the present RCTs has been agreed with four pharmaceutical companies. Central facilities, dependent on reinforced concertation, are required and will be available for the quality control of serology and histopathology, for RCT administration and central database and for training of participants in disease scoring and trial methodology. They will develop into Eurofacilities to support future studies, including public health research, systematic reviews, meta-analysis and the targeted training of young researchers.