AAV Treatment 101: Induction vs. Maintenance

“A treatment plan is not one-size-fits-all — it’s curated specifically with the individual in mind,” says Kanika Monga, MD, a rheumatologist with Houston Methodist Academic Medicine Associates. “The goal is to personalize therapy to improve both survival and quality of life.”

Phase 1: Induction Therapy (The ‘Fire Extinguisher’)

When you’re first diagnosed with AAV, you may need aggressive treatment to get the illness under control.

“At the time of diagnosis, a patient often has been living for a while with persistent, ongoing, uncontrolled inflammation in small blood vessels, which is causing irreversible damage to organs such as the kidneys and lungs,” says Christopher Palma, MD, a rheumatologist and associate professor of medicine at the University of Rochester School of Medicine and Dentistry in New York.

“So when AAV is identified, we’re pulling the handle on the fire alarm and using a ‘fire extinguisher’ of treatments to try and dampen that inflammation as quickly as possible and rapidly achieve remission,” he says.

Common Induction Medications

Usually lasting three to six months, induction therapy may involve the following medications:

• High-Dose Corticosteroids Prednisone, taken orally, can quickly reduce inflammation from vasculitis. In severe cases, methylprednisone, a stronger steroid, may be given intravenously. These are almost always used in combination with another type of medication and tapered down as quickly as possible.

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• Rituximab (Rituxan) This monoclonal antibody is a standard first-line treatment to bring about remission in active severe disease; it’s used in combination with corticosteroids and administered by IV infusion.

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• Cyclophosphamide (Cytoxan) Cyclophosphamide is primarily a chemotherapy drug that’s in a class of medications called alkylating agents. The drug (taken orally or via IV) is another effective first-line treatment option. But it’s used less often than it was before rituximab was approved because of concerns about side effects and long-term risks.

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• Benralizumab (Fasenra) The U.S. Food and Drug Administration approved this biologic drug in 2024 to treat one form of AAV called eosinophilic granulomatosis with polyangiitis (EGPA), which mainly affects your lungs. It’s a shot you give yourself under your skin.

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• Mepolizumab (Nucala) Mepolizumab is also an injectable biologic that can be used to treat (EGPA).

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• Methotrexate Originally a cancer drug, methotrexate (administered orally or as an injection under your skin) can be used in more mild AAV cases.

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• Mycophenolate mofetil (CellCept) This oral medication can also be considered in milder disease, although some research found that the drug carries a higher risk of relapse than other induction medications.

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• Avacopan (Tavenos) This is a newer medication that the FDA approved in 2021 as an add-on to standard therapy. Avacopan may replace or reduce the need for long-term corticosteroids.

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What to Expect Physically

Medications for AAV are generally considered to be safe if prescribed and monitored appropriately, according to Naomi Patel, MD, a rheumatologist with Massachusetts General Hospital in Boston.

“In every case we aim to balance the risks of treatment with the benefits of disease control, and this approach has been optimized over the years,” she says. “In AAV, particularly with any organ or life-threatening manifestations, the benefits of treatment outweigh the risks associated with treatment.”

• Weight gain
• Upset stomach
• Increased blood pressure
• Mood swings
• Insomnia
• Swelling in your legs and feet

“All around, rituximab is a better treatment than prednisone with fewer side effects,” says Dr. Palma. “But it takes two to three weeks or more for rituximab to become efficacious after being administered, so steroids are a bridge before the rituximab takes effect.”

• Infusion-related reactions
• Body aches
• Tiredness
• Nausea

Phase 2: Maintenance Therapy (The ‘Security Guard’)

Switching from induction to maintenance therapy takes careful timing and close consultation with your physician, according to Dr. Monga. Too early means the disease may not be well controlled, but too late raises your risk of medication side effects.

Many of the same medications are used in the maintenance phase, but in lower, less-frequent doses than during induction. For example, you may need weekly infusions of rituximab for induction, but switch to one every six months for maintenance, according to Palma.

“There’s a fair amount of variability when it comes to determining what’s the best regimen for maintenance,” he says. “It involves how the disease is presenting, which organs are affected, and the degree of disease severity.”

Common Maintenance Medications

• rituximab (Rituxan)
• methotrexate
• azathioprine (Imuran)
• low-dose prednisone

In certain cases, benralizumab (Fasenra), mepolizumab (Nucala), mycophenolate mofetil (CellCept), or leflunomide (Arava) may be options.

What to Expect Physically

Maintenance medications may cause some occasional gastrointestinal side effects and require monitoring your blood work, but they are generally well tolerated by most patients, according to Marissa A. Blum, MD, a rheumatologist and professor of clinical medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia. Fatigue and nausea are also common.

You’ll also continue to face a higher risk of infection than the general population.

• Insulin resistance and diabetes
• Bone loss
• Thin, fragile skin
• Glaucoma and cataracts

Recognizing Signs of Treatment Efficacy or Failure

Close monitoring of physical symptoms and regular blood work can show how well treatment is working and help identify health problems that may be caused by your medication.

“If there is intolerance to a medication, side effects, or disease relapse, patients should probably talk to their doctor about switching or adjusting medications,” says Monga.

Shared Decision-Making in AAV Care

You and your doctor should discuss the different AAV treatment options to decide what best fits your lifestyle and goals.

Dr. Blum urges patients to approach the disease as a chronic condition just as you would diabetes or high blood pressure.

“Treatment for AAV is often a long-term plan,” she says. “It’s important to see your providers regularly and take medications as prescribed. If there are concerns, communicate them early to your providers to make a plan.”

The Takeaway

• Treatment for AAV has two distinct phases — induction and maintenance.
• The first phase requires more aggressive therapy to get the condition under control.
• The maintenance phase usually involves less frequent treatments or lower medication doses and can go on for years.
• Monitoring is essential to treat relapses early on and manage treatment side effects.