Implementing the new ANCA vasculitis guidelines

Implementation of the 2025 British Society for Rheumatology (BSR) management recommendations for ANCA-associated vasculitis (AAV) is now underway across the UK – the first major update since 2014.

Developed by a multiprofessional working group spanning rheumatology, nephrology, respiratory medicine, ENT, nursing, and patient representatives, the 26 recommendations address GPA, MPA, and EGPA across the whole life course. Despite advances in treatment, AAV mortality remains 2.3 times higher than the general population, making consistent, evidence-based practice more important than ever.

What’s changed

Induction. Both rituximab (RTX) and cyclophosphamide (CYC) are recommended for newly diagnosed GPA and MPA, with neither preferred over the other. For relapsing disease, RTX is now preferred to reduce cumulative CYC toxicity.

Glucocorticoid minimisation. Reduced-dose regimens (based on PEXIVAS and LoVAS trials) are now standard. High-dose GC increases infection risk – the leading cause of excess mortality – without improving outcomes.

Avacopan. Now recommended as a steroid-sparing option for active GPA and MPA, in line with NICE approval. Use is currently limited to 12 months.

Maintenance. RTX is preferred over azathioprine or methotrexate, at 500–1000 mg every 4–6 months.

Plasmapheresis. No longer routinely recommended for pulmonary haemorrhage without severe renal involvement. Consider for creatinine >300 µmol/l, weighing infection risk carefully.

The recommendations also introduce, for the first time, explicit service specification and patient education domains – reflecting the reality that AAV care spans multiple specialties.

The full recommendations are open access in Rheumatology.