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Rituximab Fails to Beat Azathioprine for Rare Vasculitis in 98 Adults

A French trial of 98 adults with a rare blood vessel disease found rituximab did not outperform azathioprine at keeping remission.

By Dr. Josh Axe · October 31, 2026 · 1 source · Understand

Photo: Pexels

Rituximab did not beat the older drug azathioprine at keeping people with a rare autoimmune disease of the blood vessels in remission, in a randomized trial of 98 adults published October 22, 2026, in JAMA.

34.7% vs 22.4%remission

91.1 vs 96.0weeks

46.9% vs 24.5%infections

98adults, France

28-monthtrial

Rituximab did not outperform azathioprine at extending remission in people with eosinophilic granulomatosis with polyangiitis, a rare autoimmune disease that inflames small blood vessels, in a randomized trial of 98 adults (average age 59, 51% women) across 36 hospitals in France.

From March 2018 to June 2022, participants who had recently reached remission got either 500 mg of intravenous rituximab every 6 months for 18 months (49 people) or daily oral azathioprine for 24 months (49 people), both with a standardized prednisone taper. Over the 28-month study, 34.7% of the rituximab group (17 of 49) stayed in remission on 7.5 mg or less of prednisone daily, versus 22.4% of the azathioprine group (11 of 49). Average time in remission at that low dose was 91.1 weeks for rituximab versus 96.0 weeks for azathioprine. Vasculitis relapse occurred in 14.3% on rituximab versus 18.4% on azathioprine; asthma or sinus flares occurred in 32.7% versus 38.8%.

In general, both drugs damp down an overactive immune system through different routes: rituximab clears out antibody-producing immune cells called B cells, while azathioprine slows the broader production of new immune cells; this trial did not test those mechanisms. The authors conclude rituximab was not superior to azathioprine for remission duration. For a rare disease with few maintenance options, that means the newer biologic showed no remission advantage over the older, cheaper generic.

Remission Held in 34.7% on Rituximab vs 22.4% on Azathioprine

JAMA, 2026, Puéchal et al.

Severe infections were more frequent with rituximab, 46.9% (23 of 49) versus 24.5% with azathioprine (12 of 49), mostly severe COVID-19. One person on azathioprine died of COVID-19 before vaccines existed. The trial was built to show rituximab was better and didn't clear that bar; a larger trial is the next step before calling the two drugs equivalent.

Dr. Axe’s Take

The pricier biologic didn't beat a decades-old generic pill at holding this rare vasculitis in remission, and its side effect here was nearly double the severe infections, mostly COVID-19. Rituximab doesn't fix why the immune system turns on blood vessels in the first place, and neither does azathioprine. Alongside whatever treatment you're on, I'd watch closely for infections and lean into an anti-inflammatory diet, stress reduction and real sleep, the levers you control. And listen, never stop or change a medication on your own. Make that change with your practitioner.

— Dr. Axe

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Study summary

Who: 98 adults with EGPA, a rare blood vessel disease, average age 59, 51% women, 36 hospitals in France.
Design: Double-blind, double-dummy randomized trial, 28-month follow-up, 2018 to 2022.
Dose: 500 mg IV rituximab every 6 months for 18 months (n=49) vs daily oral azathioprine for 24 months (n=49), both with prednisone taper.
Primary result: 34.7% (17/49) on rituximab vs 22.4% (11/49) on azathioprine stayed in remission on low-dose prednisone; not statistically significant.
Secondary: Vasculitis relapse: 14.3% vs 18.4%; asthma/sinus flares: 32.7% vs 38.8%; mean remission time 91.1 vs 96.0 weeks.
Funding / conflicts: Competing interests: Authors consult for Boehringer Ingelheim. Funding not reported in the abstract.
Date: Oct 22, 2026