Rituximab was not superior to azathioprine for EGPA maintenance

Design

Randomised, double-blind, double-dummy superiority trial, 28 months

Population

98 adults with new or relapsing EGPA in remission, 36 French hospitals

Primary outcome

Duration of remission on prednisone ≤7.5 mg/day

Effect

91.1 vs 96.0 weeks (P=.38); severe infections 47% vs 25%

A double-blind, double-dummy trial at 36 French hospitals, enrolled 98 adults with eosinophilic granulomatosis with polyangiitis (EGPA) in remission after standard induction. They received rituximab 500 mg every six months for 18 months or daily azathioprine for 24 months, with a standard prednisone taper. Published in JAMA on 22 October 2026.

Mean time in remission on 7.5 mg/day of prednisone or less was 91 weeks with rituximab and 96 weeks with azathioprine (P = .38). Sustained remission throughout 28 months was 35% versus 22%, a difference that was not significant (RR 1.51, 95% CI 0.83 to 2.73). Vasculitis relapses and asthma or sinus flares were similar. Severe infections occurred in 47% on rituximab and 25% on azathioprine, largely COVID-19 before vaccines were available.

Rituximab has been widely adopted for maintenance in ANCA vasculitis on the strength of other trials. This result shows that what holds for granulomatosis with polyangiitis does not automatically extend to EGPA.

For most patients with EGPA in remission, azathioprine remains a reasonable and much cheaper maintenance option. The trial was small, so a modest benefit of rituximab cannot be excluded, and the infection excess may be smaller in a vaccinated population.

• Consider azathioprine as maintenance for EGPA in remission; rituximab was not better here
• Check thiopurine methyltransferase activity or genotype before starting azathioprine where available
• Weigh infection risk before choosing rituximab, and ensure vaccination is up to date
• Expect asthma and sinus symptoms to need their own treatment whichever drug is used
• Do not extrapolate rituximab maintenance data from other ANCA vasculitides to EGPA

Why it matters

It challenges the assumption that rituximab maintenance suits every ANCA-associated vasculitis.

Don't overread it

With 98 patients, the trial could miss a modest rituximab benefit; it does not show the drugs are equivalent.

The statistics, in plain English

The relative risk for sustained remission (1.51) favours rituximab, but its confidence interval runs from 0.83 to 2.73, so the result is compatible with no difference or a large benefit. A larger trial would be needed to settle it.

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