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Geng L, Pan K, Xu Y, Zhang B, Wang J, Xue Q, Zhang S, Su H, Zhang B. Antiphospholipid antibodies as potential prognostic indicators of recurrent ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107885. [PMID: 39059754 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Immunity play a pivotal role in the risk of ischemic stroke, and studies have also shown a relationship between ischemic stroke and autoimmune diseases. In light of this we conducted a prospective cohort study to elucidate the impact of antiphospholipid antibodies (aPLs), antinuclear antibodies (ANA), and anti-extractable nuclear antigen autoantibodies (anti-ENA) on the prognosis of ischemic stroke. METHODS 245 stroke patients were recruited in this single-center study and followed up with for 3 years. Autoantibodies, including aPLs (ACA, anti-β2GPI, LA), ANA and anti-ENA were evaluated in recurrent ischemic stroke (RIS) and nonrecurrent ischemic stroke (nonRIS). Stroke severity was judged using the National Institutes of Health Stroke Scale (NIHSS). For preventive treatment, 42 IS patients with positive aPLs + ANA/anti-ENA were randomized 1:1 into a hydroxychloroquine (HCQ) treatment group and a control group, and the prognoses were compared. RESULTS The positive rate of ACA IgG (p = 0.018), anti-β2GPI IgG (p = 0.047), LA (p = 0.023), and aPLs + ANA/anti-ENA (p = 0.000) were significantly higher in patients with RIS compared to patients with nonRIS, and aPLs + ANA/anti-ENA (HR2.31, 95 % CI1.02-5.25, p = 0.046) and hypertension (HR2.50, 95 % CI1.17-5.35, p = 0.018) were the independent risk factors of recurrence. There were differences in NIHSS at month 36 between those positive and negative for aPLs + ANA/anti-ENA (p = 0.001, Eta2 = 0.052), anti-ENA (p = 0.016, Eta2 = 0.030), ANA (p = 0.035, Eta2 = 0.022), and LA (p = 0.016, Eta2 = 0.028). Furthermore, the recurrence rate of the HCQ treatment group was lower than that of the control group (p = 0.024). CONCLUSIONS Co-positivity of aPLs and ANA/anti-ENA is an independent risk factor for RIS. However, HCQ therapy may reduce the recurrence rate of IS for these patients.
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Affiliation(s)
- Lina Geng
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Kai Pan
- Department of Information Management, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Yuhuan Xu
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Bizhu Zhang
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Jing Wang
- Department of Pharmacy, Zhangjiakou Second Hospital, Zhangjiakou City, Hebei Province, China
| | - Qian Xue
- Department of Neurology, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Sanming Zhang
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Hua Su
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China
| | - Bin Zhang
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, Zhangjiakou City, Hebei Province, China.
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Paredes-Ruiz D, Martin-Iglesias D, Ruiz-Irastorza G. Thrombotic antiphospholipid syndrome: From guidelines to clinical management. Med Clin (Barc) 2024; 163 Suppl 1:S22-S30. [PMID: 39174150 DOI: 10.1016/j.medcli.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 08/24/2024]
Abstract
Thrombotic manifestations, mainly venous thromboembolism (VTE) and stroke, are the most common and potentially life-threatening presentations of antiphospholipid syndrome (APS). The management of APS requires the assessment of the antiphospholipid antibodies (aPL) profile, of concurrent systemic lupus erythematosus or other systemic autoimmune diseases and the presence of risk factors for cardiovascular disease and bleeding. Anticoagulation with vitamin K antagonists (VKA) remains the cornerstone of therapy for thrombotic APS. As platelets play a central role in APS, low-dose aspirin is the first option for primary thromboprophylaxis in asymptomatic aPL carriers, and also plays a role as combination therapy with VKAs in arterial thrombosis. Treatment with direct oral anticoagulants (DOACs) could be considered in certain low-risk situations, although they are not recommended in patients with arterial thrombosis or triple positive aPL. Adjuvant therapies such as hydroxychloroquine and statins may be useful in complex settings such as thrombotic recurrences or high risk of bleeding. In this article, we review the evidence and the recommendations of the guidelines for the treatment of APS, and provide a critical and practical approach of its management from our clinical perspective.
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Affiliation(s)
- Diana Paredes-Ruiz
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biobizkaia Health Research Institute, Hospital Universitario Cruces, Spain
| | - Daniel Martin-Iglesias
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biobizkaia Health Research Institute, Hospital Universitario Cruces, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biobizkaia Health Research Institute, Hospital Universitario Cruces, Spain; University of The Basque Country, Bizkaia, The Basque Country, Spain.
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Manning JE, Arachchillage DJ. Dilemmas in the diagnosis and management of antiphospholipid syndrome. J Thromb Haemost 2024; 22:2156-2170. [PMID: 38705387 DOI: 10.1016/j.jtha.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/27/2024] [Accepted: 03/20/2024] [Indexed: 05/07/2024]
Abstract
Antiphospholipid syndrome (APS) is characterized by thrombosis (which may be venous, arterial, or microvascular) and/or pregnancy morbidity in association with persistently positive antiphospholipid antibodies. Although thrombosis and pregnancy morbidity are the main clinical criteria for a diagnosis of APS in the revised Sapporo (Sydney) criteria, recently published American College of Rheumatology/European Alliance of Associations for Rheumatology classification criteria for APS have significantly refined the diagnostic algorithm to include a scoring system clustered into 6 clinical domains (macrovascular venous thromboembolism, macrovascular arterial thrombosis, microvascular thrombosis, obstetric, cardiac valve, and hematologic). Diagnosis of APS is complicated by the fact that significant heterogeneity exists in patients' clinical presentation, underlying vascular risk factors, and methods of detecting antiphospholipid antibodies. Despite the autoimmune nature of APS, anticoagulation remains the main strategy for secondary prevention of thrombosis. Furthermore, optimal antithrombotic treatment in APS patients with arterial thrombosis remains controversial due to a paucity of data from randomized controlled studies. In this paper, we present 2 cases and highlight the diagnostic and therapeutic challenges they pose and how we approach them in the light of current evidence.
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Affiliation(s)
- James E Manning
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom; Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom; Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom.
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4
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Chighizola CB, Willis R, Maioli G, Sciascia S, Andreoli L, Amengual O, Radin M, Gerosa M, Atsumi T, de Jesus G, Trespidi L, Branch DW, Caporali R, Andrade D, Roubey R, Petri M, Bertolaccini ML. Deciphering the clinical significance of longitudinal antiphospholipid antibody titers. Autoimmun Rev 2024; 23:103510. [PMID: 38171447 DOI: 10.1016/j.autrev.2023.103510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
In antiphospholipid syndrome (APS), the risk of clinical manifestations increases with higher titers of antiphospholipid antibodies (aPL). Despite the adoption of aPL titers in the classification approach to aPL-positive subjects, the value of longitudinal monitoring of those titers in the follow-up is still debated, being well studied only in systemic lupus erythematosus (SLE). The literature suggests that the rate of aPL positivity decreases during follow-up in primary APS, estimating that seroconversion occurs in between 8.9 and 59% of patients over time. Negativisation of aPL occurs more frequently in asymptomatic aPL carriers than in patients with full-blown APS as well as in subjects with single aPL positivity or low aPL antibody titers. In patients with SLE, aPL typically behave fluctuating from positive to negative and back again in the course of follow-up. The few studies assessing the longitudinal course of aPL positivity with no associated systemic connective tissue disease reported a progressive decrement of aPL titers over time, in particular of antibodies against β2 glycoprotein I (antiβ2GPI) and cardiolipin (aCL) of IgG isotype. After a thrombotic event, aPL titers tend to decrease, as emerged from cohorts of both primary and secondary APS. Hydroxychloroquine has been identified as the most effective pharmacological agent to reduce aPL titers, with multiple studies demonstrating a parallel reduction in thrombosis rate. This review addresses available evidence on the significance of aPL titer fluctuation from clinical, therapeutic and pathogenic perspectives.
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Affiliation(s)
- Cecilia B Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Pediatric Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy.
| | - Rohan Willis
- University of Texas Medical Branch, Internal Medicine, Galveston, USA
| | - Gabriella Maioli
- Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | - Savino Sciascia
- University of Turin, Department of Clinical and Biological Sciences, Turin, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Olga Amengual
- Hokkaido University, Department of Rheumatology, Endocrinology and Nephrology Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Massimo Radin
- University of Turin, Department of Clinical and Biological Sciences, Turin, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | - Tatsuya Atsumi
- Hokkaido University, Department of Rheumatology, Endocrinology and Nephrology Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Guilherme de Jesus
- Universidade do Estado do Rio de Janeiro, Department of Obstetrics, Rio de Janeiro, Brazil
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, Pediatric Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | | | - Robert Roubey
- Department of Rheumatology, University of North Carolina, Chapel Hill, NC, USA
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Rheumatology, Baltimore, MD, USA
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Hou XJ, Chang R, Wang YH, Kang TL, Wei JCC. Hydroxychloroquine had neutral effect on long-term risk of malignancy in rheumatoid arthritis patients: A population-based retrospective cohort study. Int J Rheum Dis 2024; 27:e15102. [PMID: 38450839 DOI: 10.1111/1756-185x.15102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 01/22/2024] [Accepted: 02/17/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND The cancer risk in rheumatoid arthritis (RA) patients has been discussed. Hydroxychloroquine (HCQ) may exert protective effects against malignancy. The study investigated the association between HCQ use and the risk of subsequent malignancy in RA patients. METHODS Catastrophic illness certificated RA patients were extracted from the National Health Insurance Research Database. The index date was set 180 days after the RA diagnosis date to avoid immortal time bias. Two groups were matched in a 1-to-1 ratio by propensity score regarding age, gender, index date, relevant comorbidities, and comedication. HCQ users prior to the diagnosis of RA were exempted to ensure compliance with the new-user design. Cancers diagnosed before or less than 180 days after the index date were excluded to mitigate protopathic bias. The study adopted the Kaplan-Meier curve and Cox proportional hazards model to examine the association between HCQ use and cancer risk. The assumption of proportional hazard was also tested. RESULTS Based on strict criteria, we included 492 eligible RA patients and divided them into study and control groups (N = 246 in each group). HCQ users exhibited a neutral risk of cancer relative to the controls (adjusted hazard ratio, 0.99; 95% CI, 0.44-2.21, p > .05). The assumption of proportional hazard was not violated. CONCLUSION This study does not observe the effect of using HCQ as a primary regimen to prevent cancer in RA patients. We are assured that HCQ is not associated with an increased risk of subsequent malignancy in RA patients. Further mechanistic research is needed.
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Affiliation(s)
- Xiu-Juan Hou
- Department of Rheumatism, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Renin Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tian-Lun Kang
- Department of Rheumatism, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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Tektonidou MG. Update on antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI1-SI3. [PMID: 38320590 DOI: 10.1093/rheumatology/kead633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
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7
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Ruiz-Irastorza G, Tektonidou MG, Khamashta M. Anticoagulant and non-anticoagulant therapy in thrombotic antiphospholipid syndrome: old drugs and new treatment targets. Rheumatology (Oxford) 2024; 63:SI96-SI106. [PMID: 38320592 DOI: 10.1093/rheumatology/kead538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/21/2023] [Indexed: 02/08/2024] Open
Abstract
In this review, we discuss the current evidence on classic and newer oral anticoagulant therapy, older drugs such as HCQ and statins, and new potential treatment targets in APS. Vitamin K antagonists (VKAs) remain the cornerstone treatment for thrombotic events in APS. In patients fulfilling criteria for definite APS presenting with a first venous thrombosis, treatment with VKAs with a target international normalized ratio (INR) 2.0-3.0 is recommended. In patients with arterial thrombosis, treatment with VKA with target INR 2.0-3.0 or 3.0-4.0 is recommended by recent guidelines, considering the individual's bleeding and thrombosis recurrence risk. A combination of VKAs and low-dose aspirin (75-100 mg/daily) may also be considered. According to available evidence direct oral anticoagulants should be avoided in patients with arterial thrombosis and/or those with triple aPL positivity. Adjunctive treatment with HCQ and/or statins can be considered, especially in anticoagulation treatment-refractory APS. Potential targeted treatments in APS include B-cell targeting, complement inhibition, mammalian target of rapamycin inhibition, IFN targeting, adenosine receptors agonists, CD38 targeting or chimeric antigen receptor T-cell therapy. The safety and efficacy of these treatment targets needs to be examined in well-designed randomized controlled trials.
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Affiliation(s)
- Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, The Basque Country, Bizkaia, Spain
- University of The Basque Country, The Basque Country, Bizkaia, Spain
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Munther Khamashta
- Department of Women & Children's Health, King's College London, London, UK
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Gajić M, Schröder-Heurich B, Mayer-Pickel K. Deciphering the immunological interactions: targeting preeclampsia with Hydroxychloroquine's biological mechanisms. Front Pharmacol 2024; 15:1298928. [PMID: 38375029 PMCID: PMC10875033 DOI: 10.3389/fphar.2024.1298928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/23/2024] [Indexed: 02/21/2024] Open
Abstract
Preeclampsia (PE) is a complex pregnancy-related disorder characterized by hypertension, followed by organ dysfunction and uteroplacental abnormalities. It remains a major cause of maternal and neonatal morbidity and mortality worldwide. Although the pathophysiology of PE has not been fully elucidated, a two-stage model has been proposed. In this model, a poorly perfused placenta releases various factors into the maternal circulation during the first stage, including pro-inflammatory cytokines, anti-angiogenic factors, and damage-associated molecular patterns into the maternal circulation. In the second stage, these factors lead to a systemic vascular dysfunction with consecutive clinical maternal and/or fetal manifestations. Despite advances in feto-maternal management, effective prophylactic and therapeutic options for PE are still lacking. Since termination of pregnancy is the only curative therapy, regardless of gestational age, new treatment/prophylactic options are urgently needed. Hydroxychloroquine (HCQ) is mainly used to treat malaria as well as certain autoimmune conditions such as systemic lupus and rheumatoid arthritis. The exact mechanism of action of HCQ is not fully understood, but several mechanisms of action have been proposed based on its pharmacological properties. Interestingly, many of them might counteract the proposed processes involved in the development of PE. Therefore, based on a literature review, we aimed to investigate the interrelated biological processes of HCQ and PE and to identify potential molecular targets in these processes.
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Affiliation(s)
- Maja Gajić
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
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Isogai S, Mizuno M, Uehara K, Okita K, Naniwa T. Case report: Additional use of hydroxychloroquine in treatment-resistant recurrent cerebral infarctions with antiphospholipid antibody syndrome. Int J Rheum Dis 2024; 27:e15056. [PMID: 38334164 DOI: 10.1111/1756-185x.15056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/04/2024] [Accepted: 01/19/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Shuntaro Isogai
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Masayuki Mizuno
- Department of Neurology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Koji Uehara
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Kenji Okita
- Department of Neurology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Taio Naniwa
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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10
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Chong KM, Jiang H, Lo EAG, Hong WZ, Wong ETY, Chan GC, Cho J. Therapeutic Drug Monitoring in Patients with Systemic Lupus Erythematosus: Utility and Gaps. J Clin Med 2024; 13:451. [PMID: 38256585 PMCID: PMC10816431 DOI: 10.3390/jcm13020451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Despite advances in the treatment of patients with systemic lupus erythematous (SLE), outcomes have remained suboptimal. Persistent disease activity, patient comorbidities and drug toxicities contribute to the accrual of progressive irreversible damage and high rates of morbidity and mortality. Currently, similar drug doses and regimens are promulgated in the treatment guidelines for all SLE patients, despite the vast differences in patient and environmental factors that affect the drugs' metabolism and blood concentrations. This causes a disconnect between drug dosing and drug blood concentrations, which can then result in unpredictability in drug toxicities and therapeutic effects. In this review, we discuss commonly used oral immunosuppressive medications in SLE, their pharmacogenomics, and factors affecting their metabolism and blood concentrations. Further, we highlight the role of therapeutic drug monitoring in SLE, which is the first accessible step to individualising therapy.
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Affiliation(s)
- Kar Mun Chong
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - He Jiang
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore; (H.J.); (E.A.G.L.)
| | - Elaine Ah Gi Lo
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore; (H.J.); (E.A.G.L.)
| | - Wei-Zhen Hong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Emmett Tsz-Yeung Wong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore 119074, Singapore
| | - Gek Cher Chan
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jiacai Cho
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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11
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Fanouriakis A, Kostopoulou M, Andersen J, Aringer M, Arnaud L, Bae SC, Boletis J, Bruce IN, Cervera R, Doria A, Dörner T, Furie RA, Gladman DD, Houssiau FA, Inês LS, Jayne D, Kouloumas M, Kovács L, Mok CC, Morand EF, Moroni G, Mosca M, Mucke J, Mukhtyar CB, Nagy G, Navarra S, Parodis I, Pego-Reigosa JM, Petri M, Pons-Estel BA, Schneider M, Smolen JS, Svenungsson E, Tanaka Y, Tektonidou MG, Teng YO, Tincani A, Vital EM, van Vollenhoven RF, Wincup C, Bertsias G, Boumpas DT. EULAR recommendations for the management of systemic lupus erythematosus: 2023 update. Ann Rheum Dis 2024; 83:15-29. [PMID: 37827694 DOI: 10.1136/ard-2023-224762] [Citation(s) in RCA: 57] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To update the EULAR recommendations for the management of systemic lupus erythematosus (SLE) based on emerging new evidence. METHODS An international Task Force formed the questions for the systematic literature reviews (January 2018-December 2022), followed by formulation and finalisation of the statements after a series of meetings. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned, and participants finally provided their level of agreement with each item. RESULTS The Task Force agreed on 5 overarching principles and 13 recommendations, concerning the use of hydroxychloroquine (HCQ), glucocorticoids (GC), immunosuppressive drugs (ISDs) (including methotrexate, mycophenolate, azathioprine, cyclophosphamide (CYC)), calcineurin inhibitors (CNIs, cyclosporine, tacrolimus, voclosporin) and biologics (belimumab, anifrolumab, rituximab). Advice is also provided on treatment strategies and targets of therapy, assessment of response, combination and sequential therapies, and tapering of therapy. HCQ is recommended for all patients with lupus at a target dose 5 mg/kg real body weight/day, considering the individual's risk for flares and retinal toxicity. GC are used as 'bridging therapy' during periods of disease activity; for maintenance treatment, they should be minimised to equal or less than 5 mg/day (prednisone equivalent) and, when possible, withdrawn. Prompt initiation of ISDs (methotrexate, azathioprine, mycophenolate) and/or biological agents (anifrolumab, belimumab) should be considered to control the disease and facilitate GC tapering/discontinuation. CYC and rituximab should be considered in organ-threatening and refractory disease, respectively. For active lupus nephritis, GC, mycophenolate or low-dose intravenous CYC are recommended as anchor drugs, and add-on therapy with belimumab or CNIs (voclosporin or tacrolimus) should be considered. Updated specific recommendations are also provided for cutaneous, neuropsychiatric and haematological disease, SLE-associated antiphospholipid syndrome, kidney protection, as well as preventative measures for infections, osteoporosis, cardiovascular disease. CONCLUSION The updated recommendations provide consensus guidance on the management of SLE, combining evidence and expert opinion.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, INSERM UMR-S 1109, Centre National de Référence des Maladies Auto-immunes Systémiques Rares (RESO), Strasbourg, France
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology Research and Hanyang Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK; National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charite Universitätsmedizin Berlin; Deutsches Rheumaforschungszentrum, Berlin, Germany
| | - Richard A Furie
- Division of Rheumatology, Northwell Health, Great Neck, New York City, New York, USA
| | - Dafna D Gladman
- Lupus Program, Centre for Prognosis Studies in the Rheumatic Disease, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Frederic A Houssiau
- Service de Rhumatologie, Cliniques Universitaires Saint-Luc and Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Luís Sousa Inês
- Department of Rheumatology, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal; School of Health Sciences, Universidade da Beira Interior, Covilha, Portugal
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - László Kovács
- Department of Rheumatology and Immunology, Faculty of Medicine, University of Szeged, Hungary
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
| | - Eric F Morand
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Gabriella Moroni
- Department of Biomedical Sciences Humanitas University, Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Johanna Mucke
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - György Nagy
- Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Sandra Navarra
- Section of Rheumatology, Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - José M Pego-Reigosa
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) - VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - Michelle Petri
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bernardo A Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Joint Academic Rheumatology Program, Athens, Greece
| | - Yk Onno Teng
- Centre of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Chris Wincup
- Department of Rheumatology, King's College Hospital, London, UK
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Greece, University Hospital of Heraklion, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece, Medical School, University of Cyprus, Nicosia, Cyprus
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Karakasis P, Patoulias D, Stachteas P, Lefkou E, Dimitroulas T, Fragakis N. Accelerated Atherosclerosis and Management of Cardiovascular Risk in Autoimmune Rheumatic Diseases: An Updated Review. Curr Probl Cardiol 2023; 48:101999. [PMID: 37506959 DOI: 10.1016/j.cpcardiol.2023.101999] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 07/24/2023] [Indexed: 07/30/2023]
Abstract
Even though diagnosis and management pathways have been substantially improved over the last years, autoimmune rheumatic diseases (AIRDs) such as rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, antiphospholipid syndrome, Sjögren's syndrome, and systemic vasculitides have been linked to elevated rates of cardiovascular morbidity and mortality, primarily secondary to accelerated atherosclerosis. This phenomenon can be partially attributed to the presence of established cardiovascular risk factors but may also be a result of other inflammatory and autoimmune mechanisms that are enhanced in AIRDs. According to the current guidelines, the recommendations regarding cardiovascular disease prevention in patients with AIRDs are not significantly different from those applied to the general population. Herein, we present a review of the current literature on the risk of accelerated atherosclerosis in AIRDs and provide a summary of available recommendations for the management of cardiovascular risk in rheumatic diseases.
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Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece.
| | - Dimitrios Patoulias
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece; Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece; Second Department of Internal Medicine, European Interbalkan Medical Center, Thessaloniki, Greece
| | - Panagiotis Stachteas
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece
| | - Eleftheria Lefkou
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece; Perigenesis, Institute of Obstetric Haematology, Thessaloniki, Greece
| | - Theodoros Dimitroulas
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece; Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece
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Mayer-Pickel K, Nanda M, Gajic M, Cervar-Zivkovic M. Preeclampsia and the Antiphospholipid Syndrome. Biomedicines 2023; 11:2298. [PMID: 37626793 PMCID: PMC10452741 DOI: 10.3390/biomedicines11082298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/06/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Antiphospholipid syndrome (APS) is characterized by venous or arterial thrombosis and/or adverse pregnancy outcome in the presence of persistent laboratory evidence of antiphospholipid antibodies (aPLs). Preeclampsia complicates about 10-17% of pregnancies with APS. However, only early onset preeclampsia (<34 weeks of gestation) belongs to the clinical criteria of APS. The similarities in the pathophysiology of early onset preeclampsia and APS emphasize an association of these two syndromes. Overall, both are the result of a defective trophoblast invasion and decidual transformation at early gestation. Women with APS are at increased risk for prematurity; the reasons are mostly iatrogenic due to placental dysfunction, such as preeclampsia or FGR. Interestingly, women with APS have also an increased risk for preterm delivery, even in the absence of FGR and preeclampsia, and therefore it is not indicated but spontaneous. The basic treatment of APS in pregnancy is low-dose aspirin and low-molecular-weight heparin. Nevertheless, up to 20-30% of women develop complications at early and late gestation, despite basic treatment. Several additional treatment options have been proposed, with hydroxychloroquine (HCQ) being one of the most efficient. Additionally, nutritional interventions, such as intake of vitamin D, have shown promising beneficial effects. Curcumin, due to its antioxidant and anti-inflammatory properties, might be considered as an additional intervention as well.
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Affiliation(s)
- Karoline Mayer-Pickel
- Department of Obstetrics, Medical University Graz, 8036 Graz, Austria; (M.N.); (M.G.); (M.C.-Z.)
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14
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Liu M, Li G, Song X, Fan Y, Li C. Prevalence, risk factors, and prognosis of central nervous system manifestations in antiphospholipid syndrome. Sci Rep 2023; 13:8915. [PMID: 37264095 DOI: 10.1038/s41598-023-35955-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/26/2023] [Indexed: 06/03/2023] Open
Abstract
The central nervous system (CNS) is considered as one of the most frequently affected organs in antiphospholipid syndrome (APS). This study investigated the prevalence of CNS manifestations in APS and associated risk factors and evaluated stroke recurrence. We carried out this retrospective study from 2009 to 2021 at Peking University People's Hospital, which enrolled 342 APS patients, and 174 neurologic events were suffered by 119 patients (34.8%). Patients with and without CNS involvement were compared regarding demographics and laboratory parameters. The analysis showed that older age, livedo reticularis, and dyslipidaemia were significant related factors for CNS manifestations (P = 0.047, 0.038, and 0.030 respectively). The use of anticoagulants (P = 0.004), and/or hydroxychloroquine (P = 0.016) appeared to associated with a lower incidence of CNS manifestations. During a median follow-up of 4.1 years, 10 individuals developed new episodes of stroke in APS patients with previous ischemic strokes. Livedo reticularis, smoking and male gender may predict the risk of recurrent stroke (P = 0.020, 0.006, and 0.026 respectively). Collectively, our results indicated the protective and risk factors for CNS manifestations, as well as demonstrated that APS patients appeared at high risk of stroke recurrence despite current therapy.
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Affiliation(s)
- Meige Liu
- Department of Neurology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Gongming Li
- Department of Rheumatology and Immunology, Linyi Traditional Chinese Medicine Hospital, Shandong, China
| | - Xiaodong Song
- Department of Neurology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Yangyi Fan
- Department of Neurology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
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15
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Ambati A, Knight JS, Zuo Y. Antiphospholipid syndrome management: a 2023 update and practical algorithm-based approach. Curr Opin Rheumatol 2023; 35:149-160. [PMID: 36866678 PMCID: PMC10364614 DOI: 10.1097/bor.0000000000000932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS) is an acquired thrombo-inflammatory disease that has morbid and sometimes devastating effects on patients and their families. This review will discuss the most recent international societal treatment guidelines and propose practical management algorithms for various APS sub-types. RECENT FINDINGS APS represents a disease spectrum. Although thrombosis and pregnancy morbidities are traditional hallmarks of APS, a variety of extra-criteria clinical phenotypes can often be seen, which makes clinical management more challenging. Primary APS thrombosis prophylaxis should take a risk-stratified approach. Although vitamin K antagonists (VKAs) or heparin/low molecular weight heparin (LMWH) remain the preferred treatment for secondary APS thrombosis prophylaxis, some international society guidelines support the use of direct oral anticoagulants (DOACs) in certain circumstances. Careful monitoring and individualized obstetric care with the use of aspirin and heparin/LMWH will improve pregnancy outcomes among pregnant individuals with APS. Treatment of microvascular and catastrophic APS remains challenging. While the addition of various immunosuppressive agents is often utilized, further systemic evaluations of their use are warranted before definitive recommendations can be made. Several new therapeutic strategies are on the horizon that might enable more personalized and targeted APS management in the near future. SUMMARY Although the knowledge of APS pathogenesis has grown in recent years, the management principles and strategies are largely unchanged. There is an unmet need for evaluating pharmacological agents, beyond anticoagulants, that target diverse thromboinflammatory pathways.
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Affiliation(s)
- Amala Ambati
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Bae S, Comfort L, Ng J, Sarkar K, Pachtman S. Early HELLP Syndrome or Catastrophic Antiphospholipid Syndrome? A Diagnostic Dilemma. Cureus 2023; 15:e38244. [PMID: 37252601 PMCID: PMC10225157 DOI: 10.7759/cureus.38244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
Hypertensive disorders of pregnancy typically occur in the third trimester, with earlier presentations associated with underlying disorders such as antiphospholipid syndrome (APLS). We describe a case of a young primigravida presenting at 15 weeks 6 days gestation with epigastric pain, vomiting, new-onset severe-range hypertension, and subsequent development of anemia, thrombocytopenia, and transaminitis. Antiphospholipid antibodies (aPL) were triple-positive and imaging was negative for thrombosis. She was treated with aspirin, therapeutic anticoagulation, and ultimately dilatation and evacuation with initial postoperative improvement. Her symptoms returned postoperative day 3 and resolved following re-initiation of therapeutic anticoagulation. The differential diagnosis for hypertensive disorders of pregnancy is wide, particularly in second-trimester gestation, and includes catastrophic antiphospholipid syndrome (CAPS), lupus flare, microangiopathic anemias, and acute fatty liver of pregnancy. This case was an atypical presentation not clearly explained by any of the above diagnoses and required a multidisciplinary approach. Obstetric patients with high-risk aPL must be meticulously investigated with a broad differential to guide diagnosis and treatment.
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Affiliation(s)
- Suhwoo Bae
- Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| | - Lizelle Comfort
- Maternal Fetal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| | - Jason Ng
- Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| | - Kumar Sarkar
- Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| | - Sarah Pachtman
- Maternal Fetal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
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Hisada R, Atsumi T. An Antiphospholipid Antibody Profile as a Biomarker for Thrombophilia in Systemic Lupus Erythematosus. Biomolecules 2023; 13:biom13040617. [PMID: 37189365 DOI: 10.3390/biom13040617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/27/2023] [Accepted: 03/28/2023] [Indexed: 05/17/2023] Open
Abstract
Despite recent advances in treatment and significant improvements in prognosis, thrombosis remains the major cause of death in systemic lupus erythematosus (SLE). Antiphospholipid antibodies (aPL) are the main triggers of thrombosis in patients with SLE, with a frequency of approximately 30-40%. Lupus anticoagulant, anticardiolipin, and anti-β2-glycoprotein I antibodies, which are included in the criteria for antiphospholipid syndrome, and 'non-criteria' aPL such as anti-phosphatidylserine/prothrombin complex antibodies, are risk factors for thrombosis in patients with SLE. Multiple positivity for aPL is also associated with an increased risk of thrombosis, and scores calculated from aPL profiles can predict the risk of developing thrombosis. Although there is insufficient evidence for treatment, aPL-positive SLE patients should/may be treated with anticoagulants and/or low-dose aspirin as appropriate. This review summarises the evidence on the clinical significance of the aPL profile as a biomarker of thrombophilia in patients with SLE.
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Affiliation(s)
- Ryo Hisada
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo 060-8638, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo 060-8638, Japan
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Laurent C, Ricard L, Nguyen Y, Boffa JJ, Rondeau E, Gerotziafas G, Elalamy I, Deriaz S, De Moreuil C, Planche V, Johanet C, Millot F, Fain O, Mekinian A. Triple positive profile in antiphospholipid syndrome: prognosis, relapse and management from a retrospective multicentre study. RMD Open 2023; 9:rmdopen-2022-002534. [PMID: 37001919 PMCID: PMC10069563 DOI: 10.1136/rmdopen-2022-002534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 03/10/2023] [Indexed: 04/03/2023] Open
Abstract
ObjectiveAntiphospholipid syndrome (APS) is defined by the association of thromboembolic and/or obstetrical clinical manifestations and the presence of antiphospholipid antibodies. The objective of our study was to evaluate the impact of the triple-positive profile in a cohort of 204 APS patients.MethodsWe conducted a retrospective study, including patients with primary or secondary APS, meeting the Sydney criteria with at least one thrombotic and/or obstetrical complication. Clinical characteristics and the risk of relapse (defined by the occurrence of a new thrombotic event and/or a new adverse obstetrical event) between triple-positive and non-triple-positive APS patients were compared.Results204 patients were included in our study, 68 were triple-positive and 136 were single or double positive. 122 patients (59.8%) had primary APS. 67 patients (32.8%) had obstetrical APS, with a higher rate among triple-positive patients (45.6% vs 26.5%, p=0.010), and 170 patients (83.3%) had thrombotic APS, without difference between triple-positive and others. Thrombotic events were more often venous (56.4%) than arterial (37.7%). Triple-positive patients had more placental complications than others (17.6% vs 2.9%, p=0.001) and more non-criteria events (48.5% vs 25.7%, p=0.002). Among non-criteria events, there was a higher frequency of Sneddon syndrome in triple-positive patients (7.4% vs 0.7%, p=0.028). The relapse rate was higher in triple-positive patients than in others (63.2% vs 39,7%, p=0002). In multivariate analysis, the triple-positive profile was associated with a higher risk of relapse (HR 1.63; 95% CI 1.04 to 2.55; p=0.031).ConclusionThe triple-positivity is associated with a higher risk of relapse and obstetrical complications.
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Affiliation(s)
- Charlotte Laurent
- Sorbonne Université, AP-HP, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3), Hôpital Saint-Antoine, F-75012, Paris, France
| | - Laure Ricard
- Sorbonne Université, AP-HP, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3), Hôpital Saint-Antoine, F-75012, Paris, France
| | - Yann Nguyen
- Service de médecine médecine interne, AP-HP.Nord, Hôpital Beaujon, Université de Paris, Clichy, France
| | | | - Eric Rondeau
- Service des urgences néphrologiques et transplantation rénale, Hôpital Tenon, Paris, France
| | | | - Ismail Elalamy
- Service d'hématologie biologique, Hôpital Tenon, Paris, France
| | - Sophie Deriaz
- Service de médecine interne, Centre hospitalier et universitaire Bretonneau, Tours, France
| | - Claire De Moreuil
- Service de médecine interne, Centre hospitalier et universitaire Brest, Brest, France
| | - Virginie Planche
- Sorbonne Université, Service de Hématologie biologique, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France
| | - Cathererine Johanet
- Immunology Department, Saint-Antoine Hospital Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Francois Millot
- Service de médecine interne, Centre hospitalier et universitaire Bretonneau, Tours, France
| | - Olivier Fain
- Sorbonne Université, AP-HP, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3), Hôpital Saint-Antoine, F-75012, Paris, France
| | - Arsène Mekinian
- Sorbonne Université, AP-HP, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU i3), Hôpital Saint-Antoine, F-75012, Paris, France
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Karakasis P, Lefkou E, Pamporis K, Nevras V, Bougioukas KI, Haidich AB, Fragakis N. Risk of Subclinical Atherosclerosis in Patients with Antiphospholipid Syndrome and Subjects With Antiphospholipid Antibody Positivity: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2023; 48:101672. [PMID: 36841314 DOI: 10.1016/j.cpcardiol.2023.101672] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023]
Abstract
Currently, the guidelines for the prevention of atherosclerosis in patients with antiphospholipid syndrome (APS) do not differ substantially from those in the general population. We aimed to assess the risk of subclinical atherosclerosis in patients with APS and subjects with antiphospholipid antibody (aPL) positivity. Systematic literature search was conducted through Medline and Scopus until January 2023. Random effects meta-analyses were performed to examine the differences in markers of subclinical atherosclerosis between APS patients, subjects positive for aPLs and healthy controls. Patients with APS had significantly higher values of common carotid artery (CCA) intima-media thickness (IMT) (MD = 0.07 mm; P < 0.0001), internal carotid artery IMT (MD = 0.06 mm; P < 0.01), carotid bifurcation IMT (MD = 0.14 mm; P < 0.01) and were more frequently diagnosed with atherosclerotic plaques compared to controls (OR = 3.73; P < 0.01). Similarly, APS patients showed a decreased flow and nitrate-mediated dilation (MD = -4.52 %; <0.01, MD = -1.25 %; P < 0.05, respectively). Interestingly, comparable were the results for subjects with aPL positivity, who had higher CCA-IMT (MD = 0.06 mm; P < 0.01) and higher prevalence of atherosclerotic plaques (OR = 2.59; P = 0.08) compared to controls. Sensitivity analysis conducted on primary APS patients revealed that the risk of atherosclerosis is associated with APS per se and is not exclusively driven by other underlying conditions. Patients with APS and subjects with aPLs have an increased risk of subclinical atherosclerosis and require early and disease-specific prevention of atherosclerosis.
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Affiliation(s)
- Paschalis Karakasis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece.
| | - Elmina Lefkou
- Perigenesis, Institute of Obstetric Haematology, Thessaloniki, Greece
| | - Konstantinos Pamporis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Vasileios Nevras
- Cardiology Department, G. Gennimatas General Hospital, Thessaloniki, Greece
| | - Konstantinos I Bougioukas
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Nikolaos Fragakis
- Second Cardiology Department, Hippokrateion General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Arachchillage DJ, Laffan M, Pericleous C. Hydroxychloroquine as an Immunomodulatory and Antithrombotic Treatment in Antiphospholipid Syndrome. Int J Mol Sci 2023; 24:ijms24021331. [PMID: 36674847 PMCID: PMC9866802 DOI: 10.3390/ijms24021331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/24/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an acquired highly prothrombotic disorder in which thrombo-inflammatory antiphospholipid antibodies (aPL) cause thrombosis via multiple mechanisms, including endothelial damage and activation. Obstetric complications in APS are caused by placental thrombosis, inflammation and complement activation. Anticoagulation is poorly effective in some patients especially those with triple positive aPL who are at ~30% risk of thrombosis recurrence within 10 years. Increasing therapeutic anticoagulation intensity may be beneficial but leads to excess bleeding with serious complications, such as intracerebral haemorrhage. Nonetheless, anticoagulation is still the mainstay of treatment despite the autoimmune nature of APS. The antimalarial immunomodulatory drug hydroxychloroquine (HCQ) has been used for many years for the treatment of inflammatory rheumatic diseases. HCQ has complex pleiotropic mechanisms of action upon multiple cell types. The proposed biological processes that HCQ regulates support the hypothesis that it may be a successful adjunctive treatment in the prevention of recurrent thrombosis and pregnancy complications.
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Affiliation(s)
- Deepa J. Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London W12 0NN, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Correspondence: ; Tel.: +44-20-7351-8400; Fax: +44-20-7351-8402
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London W12 0NN, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Charis Pericleous
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
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B-Cells and BAFF in Primary Antiphospholipid Syndrome, Targets for Therapy? J Clin Med 2022; 12:jcm12010018. [PMID: 36614819 PMCID: PMC9821657 DOI: 10.3390/jcm12010018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/04/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Primary antiphospholipid syndrome (PAPS) is a systemic autoimmune disease characterized by thrombosis, pregnancy morbidity, and the presence of antiphospholipid antibodies (aPL). Anticoagulants form the mainstay of treatment in PAPS. A growing number of studies suggest a previously underappreciated role of the immune system in the pathophysiology of PAPS. Although B-cells are strongly implicated in the pathophysiology of other autoimmune diseases such as systemic lupus erythematosus (SLE), little is known about the role of B-cells in PAPS. Shifts in B-cell subsets including increases in plasmablasts and higher levels of BAFF are present in patients with PAPS. However, while treatment with rituximab and belimumab may ameliorate thrombotic and non-thrombotic manifestations of PAPS, these treatments do not reduce aPL serum levels, suggesting that B-cells contribute to the pathophysiology of APS beyond the production of autoantibodies.
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22
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Barilaro G, Coloma-Bazan E, Chacur A, Della Rocca C, Perez-Isidro A, Ruiz-Ortiz E, Viñas O, Tàssies Penella D, Reverter JC, Molina Andujar A, Cervera R, Espinosa G. Persistence of antiphospholipid antibodies over time and its association with recurrence of clinical manifestations: A longitudinal study from a single centre. Clin Exp Rheumatol 2022; 21:103208. [PMID: 36202304 DOI: 10.1016/j.autrev.2022.103208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/28/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To analyze the antiphospholipid antibody (aPL) persistence over time in patients with antiphospholipid syndrome (APS) and its association with clinical recurrence and to identify predictors of aPL persistence over time. PATIENTS AND METHODS 200 patients with a diagnosis of APS and at least three follow-up aPL determinations were included. Persistent aPL profile was defined as the presence of lupus anticoagulant (LAC) and/or IgG/IgM anticardiolipin (aCL) and/or IgG/IgM anti-β2 glycoprotein-I (aβ2GPI) (> 99th percentile) antibodies in at least 66% of follow-up measurements. Multilevel mixed-effect generalized linear models with logit link were used. RESULTS 112 (56%) patients maintained persistent aPL profiles over time, while 88 (44%) were transient. Median follow-up time was 172.5 months. Follow-up time did not affect the odds of aPL persistence in multivariate analysis (p = 1.00). Baseline triple aPL positivity [OR 78 (95%CI 16.9-359.7, p < 0.001)] and double aPL positivity [OR = 7.6 (95%CI 3.7-15.7, p < 0.001)] correlated with persistent aPLs over time, while isolated LAC [OR = 0.26 (95% CI 0.08-0.49, p = 0.002)] or isolated IgG/IgM aCL [OR = 0.20 (95% CI 0.11-0.59, p = 0.004)] positivity, were predictors of transient aPL profile. Patients with persistent aPLs had higher rate of clinical recurrence in comparison to patients with transient aPLs [OR = 2.48 (95%CI 1.34-4.58, p = 0.003)]. CONCLUSIONS More than half of patients with baseline medium-high titer aPL positivity had persistent positive aPLs over time. Patients with persistent aPLs were more prone to present recurrence of clinical manifestations. Multiple aPL positivity increased the odds of a persistent aPL profile over time, while isolated LAC and aCL positivity decreased it.
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Affiliation(s)
- Giuseppe Barilaro
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain.
| | - Emmanuel Coloma-Bazan
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - Alejandro Chacur
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Carlo Della Rocca
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina 04100, Italy
| | - Albert Perez-Isidro
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Estibaliz Ruiz-Ortiz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Odette Viñas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Dolors Tàssies Penella
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Hemotherapy and Hemostasis, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Joan Carles Reverter
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Hemotherapy and Hemostasis, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Alicia Molina Andujar
- Department of Nephrology and Renal Transplantation, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain.
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
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Niemann B, Puleo A, Stout C, Markel J, Boone BA. Biologic Functions of Hydroxychloroquine in Disease: From COVID-19 to Cancer. Pharmaceutics 2022; 14:pharmaceutics14122551. [PMID: 36559044 PMCID: PMC9787624 DOI: 10.3390/pharmaceutics14122551] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/05/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022] Open
Abstract
Chloroquine (CQ) and Hydroxychloroquine (HCQ), initially utilized in the treatment of malaria, have now developed a long list of applications. Despite their clinical relevance, their mechanisms of action are not clearly defined. Major pathways by which these agents are proposed to function include alkalinization of lysosomes and endosomes, downregulation of C-X-C chemokine receptor type 4 (CXCR4) expression, high-mobility group box 1 protein (HMGB1) inhibition, alteration of intracellular calcium, and prevention of thrombus formation. However, there is conflicting data present in the literature. This is likely the result of the complex overlapping pathways between these mechanisms of action that have not previously been highlighted. In fact, prior research has focused on very specific portions of particular pathways without describing these in the context of the extensive CQ/HCQ literature. This review summarizes the detailed data regarding CQ/HCQ's mechanisms of action while also providing insight into the overarching themes. Furthermore, this review provides clinical context to the application of these diverse drugs including their role in malaria, autoimmune disorders, cardiovascular disease, thrombus formation, malignancies, and viral infections.
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Affiliation(s)
- Britney Niemann
- Department of Surgery, West Virginia University, Morgantown, WV 26506, USA
- Correspondence: ; Tel.: +1-304-293-1254
| | - Amanda Puleo
- Department of Surgery, West Virginia University, Morgantown, WV 26506, USA
| | - Conley Stout
- Department of Surgery, West Virginia University, Morgantown, WV 26506, USA
| | - Justin Markel
- Department of Surgery, West Virginia University, Morgantown, WV 26506, USA
| | - Brian A. Boone
- Department of Surgery, West Virginia University, Morgantown, WV 26506, USA
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV 26506, USA
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24
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Wu T, Huang W, Qi J, Li Y, Zhang Y, Jiang H, Wang J, Zhang J, Jiang Z, Chen L, Ying Z. Research trends and frontiers on antiphospholipid syndrome: A 10-year bibliometric analysis (2012-2021). Front Pharmacol 2022; 13:1035229. [PMID: 36386238 PMCID: PMC9664156 DOI: 10.3389/fphar.2022.1035229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/13/2022] [Indexed: 01/24/2023] Open
Abstract
Objectives: A growing body of studies related to antiphospholipid syndrome (APS) have been published in recent years. Nevertheless, there is a lack of visualized and systematic analysis in the literature on APS. Hence, this study sought to conduct a bibliometric analysis to identify research status and discover frontiers in the field. Methods: Articles and reviews concerning APS were acquired from the Web of Science Core Collection (WoSCC) database. CiteSpace, VOSviewer and a bibliometric online analysis platform were employed to conduct a visualization and knowledge-map analysis. Results: A total of 1,390 publications regarding APS were identified. Globally, Italy contributed the most publications. The University of Padua was the most productive institution. Lupus ranked first in both the most published and most co-cited journals. Savino Sciascia and Spiros Miyakis were the most prolific and most co-cited authors, respectively. "Vitamin K antagonists (VKA)" and "immunoglobulin A (IgA)" were current research foci. Burst analysis of keywords suggested that "neutrophil extracellular trap (NET)," "direct oral anticoagulant (DOAC)," "open label," "outcome," "hydroxychloroquine (HCQ)," and "arterial thrombosis (AT)" were significant future research frontiers. Conclusion: The scientific literature on APS has increased steadily in the past 10 years. The clinical studies on the treatment and mechanism research of APS are recognized as promising research hotspots in the domain of APS. The research status and trends of APS publications from the bibliometric perspective can provide a practical guide and important reference for subsequent studies by researchers and physicians in the domain.
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Affiliation(s)
- Teng Wu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Wei Huang
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China,Qingdao University, Qingdao, China
| | - Jiaping Qi
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China,Bengbu Medical College, Bengbu, China
| | - Yixuan Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Yuan Zhang
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China,Bengbu Medical College, Bengbu, China
| | - Huan Jiang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Jing Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Ju Zhang
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Zhaoyu Jiang
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Lin Chen
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Zhenhua Ying
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China,Qingdao University, Qingdao, China,Bengbu Medical College, Bengbu, China,*Correspondence: Zhenhua Ying,
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Neurologic Manifestations of Catastrophic Antiphospholipid Syndrome. Curr Neurol Neurosci Rep 2022; 22:589-600. [PMID: 36040563 DOI: 10.1007/s11910-022-01228-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Understanding of antiphospholipid antibody syndrome (APS), associated neurological manifestations, and disease-directed treatment has grown considerably over the last decade. Herein, we critically review the current and high-yield literature related to the pathophysiology, neurological presentations, and management of APS with particular emphasis on the rare and more fatal subset of APS, catastrophic antiphospholipid syndrome (CAPS). RECENT FINDINGS APS may manifest with a variety of neurologic syndromes, with cerebrovascular disease representing the most commonly encountered presentation. Diagnostic evaluation and treatment are often tailored to the specific presentation, with suspicion and testing for antiphospholipid antibodies recommended when neurologic presentations occur atypically or in younger individuals. In CAPS, which is more rapidly progressive with multiorgan involvement, potential alternative microangiopathic syndromes should be carefully considered in the differential diagnosis. To date, anticoagulation with vitamin K antagonists remains the mainstay of therapy in APS while triple therapy with anticoagulation, corticosteroids, and plasma exchange is standard of care in CAPS. Immunotherapy has shown early promise in refractory cases. APS is an autoimmune clinical syndrome with neurologic presentations classically characterized by vascular thrombosis, though recent understandings suggest additional direct immune-mediated phenomena. Our understanding of the underlying pathogenic mechanisms of APS continues to grow and will continue to influence our therapeutic approaches.
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Hubben A, McCrae KR. Emerging Therapies in Antiphospholipid Syndrome. Transfus Med Rev 2022; 36:195-203. [PMID: 36272841 PMCID: PMC10162403 DOI: 10.1016/j.tmrv.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/15/2022]
Abstract
The antiphospholipid syndrome (APS) is the most common cause of acquired immune-mediated thrombophilia. This syndrome is broadly defined by the presence of arterial or venous thrombosis, or pregnancy morbidity, in the presence of high levels of antiphospholipid antibodies. Despite recognition of this disorder more than 50 years ago, a fundamental unifying pathogenesis has not been determined. Due to this, mechanism-based therapies for APS are not available, and current management following thrombotic events suggests anticoagulation of indeterminate duration, or for obstetric complications, heparin/low molecular weight heparin and aspirin. However, APS is an autoimmune disorder, and several approaches focused on modulating the immune response or its effectors have been employed. Those which have been most extensively studied include hydroxychloroquine, rituximab and eculizumab, an inhibitor of complement C5. In this report, we review in depth, and critique, key clinical studies of these agents. Since all of these studies are small, our conclusions are qualified. However, it appears that hydroxychloroquine may enhance the anticoagulant efficacy of vitamin K antagonists in APS patients, and that rituximab may ameliorate some of the "non-criteria" manifestations of APS. The catastrophic antiphospholipid syndrome (CAPS) is associated with diffuse thrombosis, multi-organ dysfunction, and ∼30% mortality. A high incidence of complement regulatory gene mutations, and compelling data concerning the efficacy of eculizumab in CAPS, suggests an important role for complement in this disorder. However, additional work is needed to clarify the role of complement in non-catastrophic APS, though emerging data suggests that complement inhibition may be effective in preventing thrombosis in these patients as well.
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Affiliation(s)
- Anne Hubben
- Department of Cardiovascular and Metabolic Sciences, Taussig Cancer Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Keith R McCrae
- Department of Cardiovascular and Metabolic Sciences, Taussig Cancer Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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27
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Barilaro G, Esteves A, Della Rocca C, Perez-Isidro A, Araujo O, Pires da Rosa G, Ruiz-Ortiz E, Penella DT, Viñas O, Reverter JC, Cervera R, Espinosa G. Predictive value of the Adjusted Global Anti-Phospholipid Syndrome Score on clinical recurrence in APS patients: A longitudinal study. Rheumatology (Oxford) 2022; 62:1576-1585. [PMID: 35997555 DOI: 10.1093/rheumatology/keac485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/31/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess the effect of the average adjusted global APS score (aGAPSS) over time on recurrence of clinical manifestations in APS patients through a retrospective longitudinal study. METHODS The study included 200 patients with APS. The aGAPSS was calculated for each patient at baseline and on a yearly basis for either up to 6 years (minimum 3 years) or just before the clinical event in patients who experienced clinical recurrence. The mean score per patient was computed. In patients under vitamin K antagonists (VKA) the percentage of time spent within the therapeutic range (TTR) was calculated. Cox-regression analysis was performed to determine the cut-off value of the aGAPSS with the strongest association with clinical recurrence. RESULTS Higher average aGAPSS values were found in patients who experienced clinical recurrence in comparison to patients who did not [8.81 (95% C.I. 7.53-10.08) vs 6.38 (95% C.I. 5.64-7.12), p = 0.001], patients with thrombotic recurrence compared to patients with obstetric recurrence [9.48 (95% C.I. 8.14-10.82) vs 4.25 (95% C.I. 0.85-7.65), p = 0.006], and patients with arterial thrombosis compared to patients with venous thrombosis [10.66 (S.D. 5.48) vs 6.63 (S.D. 4.42), p = 0.01]. aGAPSS values > 13 points were associated with the highest risk of recurrence in multivariate analysis [HR = 3.25 (95% C.I. 1.93-5.45, p < 0.0001]. TTR was not statistically different between patients who had thrombosis recurrence and patients who had not. CONCLUSIONS Our data support the role of periodic (annual) monitoring of the aGAPSS score in predicting clinical recurrence in patients with APS.
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Affiliation(s)
- Giuseppe Barilaro
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
| | - Alexandra Esteves
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Carlo Della Rocca
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy 04100
| | - Albert Perez-Isidro
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Olga Araujo
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
| | - Gilberto Pires da Rosa
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
| | - Estibaliz Ruiz-Ortiz
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Dolors Tàssies Penella
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Hemotherapy and Hemostasis Department, ICMHO (Institut Clinic de Malalties Hematologiques i Oncologiques),Hospital Clinic, Barcelona, Catalonia, Spain
| | - Odette Viñas
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Joan Carles Reverter
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Hemotherapy and Hemostasis Department, ICMHO (Institut Clinic de Malalties Hematologiques i Oncologiques),Hospital Clinic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
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Treatment advances in antiphospholipid syndrome: 2022 update. Curr Opin Pharmacol 2022; 65:102212. [DOI: 10.1016/j.coph.2022.102212] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/11/2022] [Indexed: 12/22/2022]
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Huang Y, Liu H, Qi W, Du L, Li M, Zeng X, Guo X, Zhao J, Zhang S. Sex Differences in Clinical Characteristics and Prognosis in Primary Thrombotic Antiphospholipid Syndrome. Front Cardiovasc Med 2022; 9:895098. [PMID: 35859586 PMCID: PMC9289156 DOI: 10.3389/fcvm.2022.895098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives This study aimed to investigate whether there are sex differences in clinical characteristics and prognosis in patients with primary thrombotic antiphospholipid syndrome (ptAPS). Methods From January 2013 to July 2021, 154 consecutive patients diagnosed with ptAPS were prospectively recruited. Multivariable Cox regression was used to evaluate the association between gender and the composite endpoint including thromboembolic recurrence or all-cause death during follow-up. Results Totally, 80 (52%) male and 74 (48%) female patients with ptAPS were included, and men had a higher percentage of smokers/ex-smokers [50 (62%) vs. 6 (8%), p < 0.001] and hyperhomocysteinemia [26 (32%) vs. 9 (12%), p = 0.003]. The baseline thromboembolic events were similar in two genders, except for limb ischemia [15 (19%) in men vs. 1 (1%) in women, p < 0.001]. During a median follow-up of 42 months, the composite endpoint occurred in 30 (38%) male and 15 (20%) female patients (p = 0.019). Male gender [HR 2.499, 95% CI (1.316, 4.743), p = 0.005] and warfarin administration [HR 0.482, 95% CI (0.257, 0.905), p = 0.023] remained independent risk factors for the composite endpoint. Male gender [HR 3.699, 95% CI (1.699, 8.246), p = 0.001] and isolated lupus anticoagulant positivity [HR 2.236, 95% CI (1.039, 4.811), p = 0.040] were independent risk factors for thromboembolic recurrence. Conclusion There are sex disparities in the clinical characteristics in patients with ptAPS and the male gender is an independent risk factor for the poor prognosis. Male patients with isolated lupus anticoagulant (LA) positivity have the highest risk of thromboembolic recurrence.
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Affiliation(s)
- Yongfa Huang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Huazhen Liu
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Wanting Qi
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Le Du
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoxiao Guo
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Xiaoxiao Guo,
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
- Jiuliang Zhao,
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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Ben Mrid R, Bouchmaa N, Ainani H, El Fatimy R, Malka G, Mazini L. Anti-rheumatoid drugs advancements: New insights into the molecular treatment of rheumatoid arthritis. Biomed Pharmacother 2022; 151:113126. [PMID: 35643074 DOI: 10.1016/j.biopha.2022.113126] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/13/2022] [Accepted: 05/13/2022] [Indexed: 11/02/2022] Open
Abstract
Rheumatoid arthritis (RA) is one of more than 100 types of arthritis. This chronic autoimmune disorder affects the lining of synovial joints in about 0.5% of people and may induce severe joints deformity and disability. RA impacts health life of people from all sexes and ages with more prevalence in elderly and women people. Significant improvement has been noted in the last two decades revealing the mechanisms of the development of RA, the improvement of the early diagnosis and the development of new treatment options. Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease-modifying antirheumatic drugs (DMARDs) remain the most known treatments used against RA. However, not all patients respond well to these drugs and therefore, new solutions are of immense need to improve the disease outcomes. In the present review, we discuss and highlight the recent findings concerning the different classes of RA therapies including the conventional and modern drug therapies, as well as the recent emerging options including the phyto-cannabinoid and cell- and RNA-based therapies. A better understanding of their mechanisms and pathways might help find a specific target against inflammation, cartilage damage, and reduce side effects in arthritis.
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Affiliation(s)
- Reda Ben Mrid
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Najat Bouchmaa
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Hassan Ainani
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Rachid El Fatimy
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Gabriel Malka
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco
| | - Loubna Mazini
- Institute of Biological Sciences (ISSB-P), Mohammed VI Polytechnic University (UM6P), 43150 Ben-Guerir, Morocco.
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Liu J, Zhang L, Tian Y, Wan S, Hu M, Song S, Zhang M, Zhou Q, Xia Y, Wang X. Protection by hydroxychloroquine prevents placental injury in obstetric antiphospholipid syndrome. J Cell Mol Med 2022; 26:4357-4370. [PMID: 35770338 PMCID: PMC9344817 DOI: 10.1111/jcmm.17459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 12/15/2022] Open
Abstract
Obstetric antiphospholipid syndrome (OAPS) is mediated by antiphospholipid antibodies (aPLs, and anti‐β2 glycoprotein I antibody is the main pathogenic antibody), and recurrent abortion, preeclampsia, foetal growth restriction and other placental diseases are the main clinical characteristics of placental pathological pregnancy. It is a disease that seriously threatens the health of pregnant women. Hydroxychloroquine (HCQ) was originally used as an anti‐malaria drug and has now shown benefit in refractory OAPS where conventional treatment has failed, with the expectation of providing protective clinical benefits for both the mother and foetus. However, its efficacy and mechanism of action are still unclear. After clinical data were collected to determine the therapeutic effect, human trophoblast cells in early pregnancy were prepared and treated with aPL. After the addition of HCQ, the proliferation, invasion, migration and tubule formation of the trophoblast cells were observed so that the therapeutic mechanism of HCQ on trophoblast cells could be determined. By establishing an obstetric APS mouse model similar to the clinical situation, we were able to detect the therapeutic effect of HCQ on pathological pregnancy. The normal function of trophoblast cells is affected by aPL. Antibodies reduce the ability of trophoblast cells to invade and migrate and can impair tubule formation, which are closely related to placental insufficiency. HCQ can partially reverse these side effects. In the OAPS mouse model, we found that HCQ prevented foetal death and reduced the incidence of pathological pregnancy. Therefore, HCQ can improve pregnancy outcomes and reverse the aPL inhibition of trophoblast disease. In OAPS, the use of HCQ needs to be seriously considered.
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Affiliation(s)
- Jing Liu
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Liting Zhang
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Yijia Tian
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Shuting Wan
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Min Hu
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Shasha Song
- Maternal and Child Health Care Hospital of Shandong Province, Jinan, China
| | - Meihua Zhang
- The Laboratory of Placenta-Related Diseases, Key Laboratory of Birth Regulation and Control Technology of National Health and Family Planning Commission of China, Jinan, China
| | - Qian Zhou
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Yu Xia
- Central Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xietong Wang
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, China.,Maternal and Child Health Care Hospital of Shandong Province, Jinan, China.,The Laboratory of Placenta-Related Diseases, Key Laboratory of Birth Regulation and Control Technology of National Health and Family Planning Commission of China, Jinan, China
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Ruiz-Irastorza G, Khamashta MA. What are the prospects for antiplatelet agents for thromboprophylaxis in antiphospholipid syndrome? Expert Rev Clin Immunol 2022; 18:779-781. [PMID: 35703006 DOI: 10.1080/1744666x.2022.2090338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, University of the Basque Country, Bizkaia, Spain
| | - Munther A Khamashta
- Women & Children's Health, King's College London, UK.,GSK, Dubai, United Arab Emirates
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Shen J, Tao Z, Chen W, Sun J, Li Y, Fu F. Malignant Isolated Cortical Vein Thrombosis as the Initial Manifestation of Primary Antiphospholipid Syndrome: Lessons on Diagnosis and Management From a Case Report. Front Immunol 2022; 13:882032. [PMID: 35547735 PMCID: PMC9082262 DOI: 10.3389/fimmu.2022.882032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/28/2022] [Indexed: 11/15/2022] Open
Abstract
Background Antiphospholipid syndrome (APS) with isolated cortical vein thrombosis (ICoVT) is an extremely rare but potentially malignant entity. It is particularly challenging to diagnose APS-related ICoVT because of the non-specific clinical manifestations and the frequent absence of typical neuroimaging. Moreover, there is currently limited knowledge on the clinical features and management strategies for the condition. Delays in diagnosis and treatment may lead to life-threatening consequences. Case Presentation We present a rare case of a 74-year-old Chinese woman who presented with sudden onset of headache and right arm weakness that mimicked acute ischemic stroke. Her initial computed tomography was unremarkable, and intravenous thrombolysis was performed. Serial neuroimages confirmed ICoVT 4 days after symptom onset, and low-molecular-weight heparin (LMWH) was started at a dose of 0.4 ml twice per day, according to the 2019 Chinese guidelines. The workup for the predisposing causes of ICoVT revealed triple positivity APS. LMWH dose was adjusted according to the anti-Xa chromogenic assay. However, the patient’s condition deteriorated rapidly, and there was a progressive enlargement of the venous infarction despite treatment with anticoagulants. Transtentorial herniation developed on day 12, and decompressive craniectomy was immediately performed. The patient’s symptoms did not improve significantly after surgery, and she remained aphasic and hemiplegic at the 3-month follow-up, with a modified Rankin Scale score of 5. Conclusion ICoVT is a rare yet potentially fatal manifestation of APS, and its diagnosis and treatment are extremely challenging. Timely diagnosis, prompt treatment, and close monitoring are essential to improve the clinical prognosis of patients with APS-related ICoVT.
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Affiliation(s)
- Jie Shen
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zi Tao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Chen
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jing Sun
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yan Li
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Fangwang Fu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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34
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Niznik S, Rapoport MJ, Avnery O, Lubetsky A, Haj Yahia S, Ellis MH, Agmon-Levin N. Patterns of Recurrent Thrombosis in Primary Antiphospholipid Syndrome-Multicenter, Real-Life Long-Term Follow-Up. Front Immunol 2022; 13:843718. [PMID: 35514968 PMCID: PMC9063725 DOI: 10.3389/fimmu.2022.843718] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 03/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Antiphospholipid syndrome (APS) is an acquired hypercoagulable condition associated with antiphospholipid antibody (aPL) presence. Data on re-thrombosis following APS-diagnosis are limited. Methods This is a retrospective analysis of new thrombotic events among primary APS (pAPS) patients followed for up to 15 years in three medical centers in Israel. Results Among 312 primary-APS patients, 143 (46%) had new thrombotic event classified to three patterns: (1) Arterial—associated with heart valve disease (OR 7.24, 95% C.I. 2.26–24.6), hypertension (OR 3, 95% C.I. 1.44–6.25), elevated anti-B2-GPI IgM (OR 1.04, 95% C.I. 0.996–1.08), arterial thrombosis at presentation (OR 1.74 95% C.I. 0.992–3.26), and older age (41 vs. 34 years, p < 0.001). (2) Venous—linked with venous thrombosis at presentation (OR 12.9, 95% C.I. 5.27–31.6, p < 0.001), heart valve disease (OR 9.81 95% C.I. 1.82–52.9, p = 0.018), aGAPSS (OR 1.15 95% C.I. 1.02–1.29), and younger age (31 vs. 36.5 years, p = 0.001); and (3) Combined pattern—associated with heart valve disease (OR 40.5 95% C.I. 7.7–212) and pulmonary embolism (OR 7.47 95% C.I. 1.96–28.5). A 4th variant “the Breakthrough pattern” defined by re-thrombosis despite prophylactic therapy was observed in 100/143 (70%) patients and linked with heart valve disease (OR 8. 95% C.I. 2.43–26.3), venous thrombosis at presentation (OR 2.61 95% C.I. 1.47–4.66), leg ulcers (OR 12.2, 95% C.I. 1.4–107), hypertension (OR 1.99, 95% C.I. 0.92–4.34), and higher aGAPSS (OR 1.08, 95% C.I. 0.99–1.18). Conclusion In this real-life observation, re-thrombosis was common among pAPS patients including in those recommended to receive prophylactic therapy. Different patterns of recurrence were identified and linked with presenting symptoms, specific serological markers, APS manifestations, and comorbidities. Studies that will address interventions to prevent recurrences of APS-related events are needed.
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Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel
| | - Micha J Rapoport
- Department of Internal Medicine "C", Shamir Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Aharon Lubetsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The National Hemophilia Center and Thrombosis Unit, Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Ramat Gan, Israel
| | - Soad Haj Yahia
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin H Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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35
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Xie W, Ji L, Zhang Z. Sirolimus Monotherapy for Thrombocytopenia in Primary Antiphospholipid Syndrome: A Pilot Study From a Tertiary Referral Center. Front Immunol 2022; 13:857424. [PMID: 35401500 PMCID: PMC8989728 DOI: 10.3389/fimmu.2022.857424] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/25/2022] [Indexed: 01/20/2023] Open
Abstract
Background Thrombocytopenia (TP) is considered as a warning sign of high-risk antiphospholipid syndrome (APS) and sometimes a paradoxical sign of anti-thrombosis treatment. Currently, there is an extreme paucity of effective and safe drugs for long-term management of TP in primary APS patients; therefore, we explored the efficacy and safety of sirolimus monotherapy. Methods In this real-world study, we included 7 consecutive patients with primary APS who received sirolimus monotherapy for TP. Oral sirolimus was initiated at a dose of 1–2 mg once daily and then adjusted primarily based on clinical efficacy and tolerance, with consideration of the sirolimus trough concentration of ≤15 ng/ml. Results Of included patients, the median age was 58 years with a median disease course of 1.5 years and 4 patients were treatment-naïve. All patients completed 6 months of sirolimus therapy with a median follow-up of 6 months (range: 6–15). All patients received sirolimus monotherapy for TP during the entire follow-up, without any additional agents. Overall, the platelet count exhibited a substantially increasing trend after sirolimus administration during the first 6 months (p < 0.001) and stability later. Specifically, the median platelet count was significantly increased from 59 × 109/l before sirolimus to 90 × 109/l at month 1 (p = 0.028), 131 × 109/l at 3 months (p = 0.028), and 178 × 109/l at 6 months (p = 0.018). Overall and complete responses were respectively achieved in 6 (85.7%) and 5 (71.4%) patients at month 6. Importantly, overall response was achieved in all 4 treatment-naïve patients. Additionally, there were different extents of decline in the titers of antiphospholipid antibodies after sirolimus treatment. Regarding safety, only one patient experienced an elevated cholesterol level with recovery after atorvastatin treatment. Conclusion Sirolimus monotherapy confers good efficacy and tolerance for TP in primary APS patients and therefore may be considered as a first-line therapy.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
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36
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Sciascia S, Foddai SG, Alessandri C, Alunno A, Andreli L, Barinotti A, Calligaro A, Canti V, Carubbi F, Cecchi I, Chighizola CB, Conti F, Emmi G, Fioravanti A, Fischetti F, Franceschini F, Gerosa M, Hoxha A, Larosa M, Lazzaroni MG, Nalli C, Pazzola G, Radin M, Raffeiner B, Ramoni V, Rubini E, Sebastiani GD, Truglia S, Urban ML, Roccatello D, Tincani A. Clinical Delphi on aPLnegativization: report from the from the APS Study Group of the Italian Society for Rheumatology (SIR-APS). Thromb Haemost 2022; 122:1612-1620. [PMID: 35292950 DOI: 10.1055/a-1798-2400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The rate of antiphospholipid antibodies (aPL) negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion. Evaluate the clinical approach and level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario. Experts of SIR-APS were contacted using a survey methodology. A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost full consensus exist among experts in some clinical settings, including: a) the role of aPL negativization in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%); b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of "extra criteria" aPL antibodies testing before pondering VKA suspension (93%). A substantial agreement exists among expert on how to define aPL negativization. VKA suspension should be embraced with extreme caution, particularly in case of previous thrombotic events and/or triple aPL positivity. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for "extra criteria" is ruled out.
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Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy., University of Turin, Torino, Italy
| | - Silvia Grazietta Foddai
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy., University of Turin, Torino, Italy
| | - Cristiano Alessandri
- Lupus Clinic, Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy., University of Rome La Sapienza, Rome, Italy
| | - Alessia Alunno
- Internal Medicine and Nephrology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy, University of L'Aquila Department of Clinical Medicine Life Health and Environmental Sciences, L'Aquila, Italy
| | - Laura Andreli
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy., University of Brescia, Brescia, Italy
| | - Alice Barinotti
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy, University of Padua, Padova, Italy
| | - Valentina Canti
- Division of Immunology, IRCCS San Raffaele Scientific Institute, Milan, Italy, San Raffaele Hospital, Milano, Italy
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy., University of L'Aquila Department of Clinical Medicine Life Health and Environmental Sciences, L'Aquila, Italy
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Cecilia B Chighizola
- Division of Rheumatology, Department of Clinical Sciences and Community Health, Ospedale Gaetano Pini, University of Milan, Milan, Italy, University of Milan, Cusano Milanino, Italy
| | - Fabrizio Conti
- Lupus Clinic, Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy, University of Rome La Sapienza, Rome, Italy
| | - Giacomo Emmi
- Internal Interdisciplinary Medicine Unit, Lupus Clinic, Departmentof Experimental and Clinical Medicine, University of Firenze, Firenze, Italy, University of Florence, Firenze, Italy
| | - Antonella Fioravanti
- Rheumatology Unit, Department of Medicine, Surgery and Neuroscience, Azienda Ospedaliera Universitaria Senese, Siena, Italy, University of Siena, Siena, Italy
| | - Fabio Fischetti
- Rheumatology Unit, SUGI and Clinical University Department of Medical, Surgery and Health Sciences, University of Trieste, Italy, University of Trieste, Trieste, Italy
| | - Franco Franceschini
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, University of Brescia, Brescia, Italy
| | - Maria Gerosa
- Division of Rheumatology, Department of Clinical Sciences and Community Health, Ospedale Gaetano Pini, University of Milan, Milan, Italy, University of Milan, Milano, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy.,Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy, University of Padua, Padova, Italy
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy, University of Padua, Padova, Italy
| | - Maria-Grazia Lazzaroni
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, University of Brescia, Brescia, Italy
| | - Cecilia Nalli
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, University of Brescia, Brescia, Italy
| | - Giulia Pazzola
- Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia, Reggio Emilia, Italy, University of Modena e Reggio Emilia, Modena, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Bernd Raffeiner
- Rheumatology Unit, Department of Medicine, Bolzano, Italy, Free University of Bozen-Bolzano, Bolzano, Italy
| | - Veronique Ramoni
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, University of Pavia, Pavia, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Gian Domenico Sebastiani
- U.O.C. Reumatologia, Ospedale San Camillo-Forlanini, Roma, Italy, San Camillo Forlanini Foundation, Roma, Italy
| | - Simona Truglia
- Lupus Clinic, Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy, University of Rome La Sapienza, Rome, Italy
| | - Maria Letizia Urban
- Internal Interdisciplinary Medicine Unit, Lupus Clinic, Departmentof Experimental and Clinical Medicine, University of Firenze, Firenze, Italy, University of Florence, Firenze, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, University of Brescia, Brescia, Italy
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Tektonidou MG. Cardiovascular disease risk in antiphospholipid syndrome: Thrombo-inflammation and atherothrombosis. J Autoimmun 2022; 128:102813. [PMID: 35247655 DOI: 10.1016/j.jaut.2022.102813] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 12/11/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by the presence of antiphospholipid antibodies (aPL) (lupus anticoagulant, anticardiolipin antibodies and anti-beta2glycoprotein I (anti-β2GPI) antibodies) and a plethora of macro- and micro-vascular manifestations, affecting predominantly young adults. Cardiovascular events are the leading causes of morbidity and mortality in APS. APL-mediated thrombo-inflammation and atherothrombosis are emerging pathogenetic mechanisms of cardiovascular disease (CVD) in APS, involving endothelial cell and monocyte activation, cytokines and adhesion molecules expression, complement and neutrophils activation, neutrophil extracellular traps formation, platelet cell activation and aggregation, and subsequent thrombin generation, in parallel with an oxidized low-density lipoprotein (oxLDL)-β2GPI complex induced macrophage differentiation to foam cells. High risk aPL profile, especially the presence of lupus anticoagulant and triple aPL positivity (all three aPL subtypes), co-existence with Systemic Lupus Erythematosus (SLE), as well as traditional risk factors such as smoking, hypertension, hyperlipemia and obesity are associated with both subclinical atherosclerosis and cardiovascular events in APS. Increased awareness of CVD risk by the physicians and patients, regular assessment and strict control of traditional risk factors, and lifestyle modifications are recommended. Use of low-dose aspirin should be considered for cardiovascular prevention in asymptomatic aPL carriers or SLE patients with high-risk aPL profile. The role of older agents such as hydroxychloroquine and statins or new potential targeted treatments against immuno- and athero-thrombosis has been demonstrated by experimental and some clinical studies and needs to be further evaluated by randomized controlled studies. This review summarizes the available evidence about the pathogenetic mechanisms and prevalence of cardiovascular events and subclinical atherosclerosis, the interrelationship between traditional and disease-related CVD risk factors, and the cardiovascular risk assessment and management in APS.
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Affiliation(s)
- Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
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38
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Drosos GC, Vedder D, Houben E, Boekel L, Atzeni F, Badreh S, Boumpas DT, Brodin N, Bruce IN, González-Gay MÁ, Jacobsen S, Kerekes G, Marchiori F, Mukhtyar C, Ramos-Casals M, Sattar N, Schreiber K, Sciascia S, Svenungsson E, Szekanecz Z, Tausche AK, Tyndall A, van Halm V, Voskuyl A, Macfarlane GJ, Ward MM, Nurmohamed MT, Tektonidou MG. EULAR recommendations for cardiovascular risk management in rheumatic and musculoskeletal diseases, including systemic lupus erythematosus and antiphospholipid syndrome. Ann Rheum Dis 2022; 81:768-779. [PMID: 35110331 DOI: 10.1136/annrheumdis-2021-221733] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/05/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To develop recommendations for cardiovascular risk (CVR) management in gout, vasculitis, systemic sclerosis (SSc), myositis, mixed connective tissue disease (MCTD), Sjögren's syndrome (SS), systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). METHODS Following European League against Rheumatism (EULAR) standardised procedures, a multidisciplinary task force formulated recommendations for CVR prediction and management based on systematic literature reviews and expert opinion. RESULTS Four overarching principles emphasising the need of regular screening and management of modifiable CVR factors and patient education were endorsed. Nineteen recommendations (eleven for gout, vasculitis, SSc, MCTD, myositis, SS; eight for SLE, APS) were developed covering three topics: (1) CVR prediction tools; (2) interventions on traditional CVR factors and (3) interventions on disease-related CVR factors. Several statements relied on expert opinion because high-quality evidence was lacking. Use of generic CVR prediction tools is recommended due to lack of validated rheumatic diseases-specific tools. Diuretics should be avoided in gout and beta-blockers in SSc, and a blood pressure target <130/80 mm Hg should be considered in SLE. Lipid management should follow general population guidelines, and antiplatelet use in SLE, APS and large-vessel vasculitis should follow prior EULAR recommendations. A serum uric acid level <0.36 mmol/L (<6 mg/dL) in gout, and disease activity control and glucocorticoid dose minimisation in SLE and vasculitis, are recommended. Hydroxychloroquine is recommended in SLE because it may also reduce CVR, while no particular immunosuppressive treatment in SLE or urate-lowering therapy in gout has been associated with CVR lowering. CONCLUSION These recommendations can guide clinical practice and future research for improving CVR management in rheumatic and musculoskeletal diseases.
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Affiliation(s)
- George C Drosos
- First Department of Propaedeutic Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Daisy Vedder
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Eline Houben
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Laura Boekel
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Internal Medicine, University of Messina, Messina, Italy
| | - Sara Badreh
- EULAR Patient Research Partner, Brussels, Belgium
| | - Dimitrios T Boumpas
- 4th Department of Internal Medicine, "Attikon" University Hospital, Athens, Greece.,Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nina Brodin
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden.,Department of Orthopaedics, Danderyd Hospital Corp, Stockholm, Sweden
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Miguel Ángel González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla and University of Cantabria, Santander, Spain
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - György Kerekes
- Intensive Care Unit, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | | | - Chetan Mukhtyar
- Rheumatology Department, Norfolk and Norwich University Hospital, Colney Lane, UK
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, University of Barcelona, Hospital Clínic, Barcelona, Spain
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Karen Schreiber
- EMEUNET member, Danish Hospital for Rheumatic Diseases, Sonderburg, Denmark
| | - Savino Sciascia
- EMEUNET member, CMID-Nephrology, San Giovanni Bosco Hospital, University of Torino, Torino, Italy
| | - Elisabet Svenungsson
- Department of Medicine, Rheumatology Unit, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Zoltan Szekanecz
- Department of Rheumatology, University of Debrecen Faculty of Medicine, Debrecen, Hungary
| | - Anne-Kathrin Tausche
- Department of Rheumatology, University Clinic Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Alan Tyndall
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | - Vokko van Halm
- Department of Cardiology, Amsterdam University Medical Center, location VU University medical center, Amsterdam, The Netherlands
| | - Alexandre Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael T Nurmohamed
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.,Amsterdam University Medical Center, location VU University Medical Centre, Amsterdam, The Netherlands
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece .,Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Barros Edington FL, de Rezende DF, Dos Santos LFS, Garcia RV, Gadelha SR, Santiago MB. Efficacy of hydroxychloroquine in the prevention of thromboembolic events: A systematic review and meta-analysis. Lupus 2022; 31:238-245. [PMID: 35041536 DOI: 10.1177/09612033221074192] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To estimate the risk ratio (RR) of thromboembolic events in chloroquine and hydroxychloroquine users compared to non-users. METHODS We systematically reviewed randomized controlled trials (RCTs), using MEDLINE and EMBASE databases from inception to the present, reporting thromboembolic events in chloroquine and hydroxychloroquine users compared to non-users. Four authors independently screened all the records obtained through our search strategy and later revised the selected full-text articles for eligibility, according to our inclusion criteria. The same four authors independently extracted relevant data through a customized data collection form while two other authors assessed the quality of the included RCTs using the Cochrane risk-of-bias tool (Version 2.0). All the disagreements were resolved through discussions among the authors. We calculated the risk ratio (RR) and its respective standard error of developing thromboembolic events in hydroxychloroquine users and non-users for each individual study and pooled the results using a random effects model meta-analysis. We assessed Heterogeneity using the Tau2 and I2, and publication bias using funnel plotting and Egger's regression. The protocol for this systematic review is registered at the PROSPERO database (CRD42021247902). RESULTS Thirteen RCTs met our eligibility criteria and were included in our analysis (2663 patients). We found that hydroxychloroquine-no study on chloroquine was found-reduced the risk of thromboembolic events by 49% (RR 0.51[IC 95% 0.31-0.84]) with a medium heterogeneity (I2 = 67% and T2 = 0.4948). We did find some asymmetry in the inspection of the funnel plot, which was ruled out through an Egger's regression (p-value = 0.1025). CONCLUSION Our data reinforce the idea that hydroxychloroquine reduces the risk of thromboembolic events.
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Affiliation(s)
- Fernando Luiz Barros Edington
- 156427Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil.,74361Universidade Estadual de Santa Cruz, Ilhéus, Brazil
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Abstract
PURPOSE OF REVIEW To review the recent available evidence on epidemiology, pathogenesis, clinical phenotypes, and management of antiphospholipid syndrome (APS) and summarize potential future research perspectives. RECENT FINDINGS Accumulating evidence has further expanded our understanding of the disease, including new data about the incidence and prevalence of APS, novel pathways supporting the role of thrombo-inflammation in APS including platelet, monocyte and endothelial cell activation, pro-inflammatory cytokine and chemokine production, complement activation, neutrophil extracellular trap release, and type I interferon gene expression that could yield to new potential treatment targets, better identification of criteria and non-criteria clinical phenotypes, antiphospholipid antibody profiles and their associations with clinical outcomes, prognostic tools, and treatment strategies based on recent evidence-based recommendations for patients with thrombotic and obstetric APS, with or without systemic lupus erythematosus. Ongoing research efforts and international collaborations enhance our knowledge of this rare and often devastating syndrome and help improve patient care and health outcomes.
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Affiliation(s)
- Eleni Xourgia
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria G Tektonidou
- Department of Propaedeutic Internal Medicine, Medical School, Rheumatology UnitJoint Academic Rheumatology Program - EULAR Centre of Excellence'Laiko' Hospital, National and Kapodistrian University of Athens, 17 Agiou Thoma str, 11527, FirstAthens, Greece.
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Islabão AG, Trindade VC, da Mota LMH, Andrade DCO, Silva CA. Managing Antiphospholipid Syndrome in Children and Adolescents: Current and Future Prospects. Paediatr Drugs 2022; 24:13-27. [PMID: 34904182 PMCID: PMC8667978 DOI: 10.1007/s40272-021-00484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
Abstract
Pediatric antiphospholipid syndrome (APS) is a rare acquired multisystem autoimmune thromboinflammatory condition characterized by thrombotic and non-thrombotic clinical manifestations. APS in children and adolescents typically presents with large-vessel thrombosis, thrombotic microangiopathy, and, rarely, obstetric morbidity. Non-thrombotic clinical manifestations are frequently seen in pediatric APS and may be present even before the vascular thrombotic events occur. We review insights into the pathogenesis of APS and discuss potential targets for therapy. The identification of multiple immunologic abnormalities in patients with APS reveals molecular targets for current or future treatment. Management strategies, especially for APS in adolescents, require screening for additional prothrombotic risk factors and consideration of counseling regarding contraceptive strategies, lifestyle recommendations, treatment adherence, and mental health issues associated with this autoimmune thrombophilia. The main goal of therapy in pediatric APS is the prevention of thrombosis. The management of acute thrombosis events in children and adolescents is the same as for primary APS, which involves isolated occurrences, and secondary APS, which is seen in association with another autoimmune disease, e.g., systemic lupus erythematosus. A pediatric hematologist should be consulted so other differential thrombophilic conditions can be eliminated. Therapy includes unfractionated heparin or low-molecular-weight heparin followed by vitamin K antagonists. Treatment of catastrophic APS involves triple therapy (anticoagulation, intravenous corticosteroid pulse therapy, and plasma exchange) and may include intravenous immunoglobulin for children and adolescents with this condition. New drugs such as eculizumab and sirolimus seem to be promising drugs for APS.
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Affiliation(s)
- Aline Garcia Islabão
- Pediatric Rheumatology Unit, Hospital da Criança de Brasília Jose Alencar, Brasília, DF Brazil ,Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF Brazil
| | - Vitor Cavalcanti Trindade
- Faculdade de Medicina, Children and Adolescent Institute, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647-Cerqueira César, São Paulo, SP 05403-000 Brazil
| | - Licia Maria Henrique da Mota
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF Brazil ,Rheumatology Unit, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
| | | | - Clovis Artur Silva
- Faculdade de Medicina, Children and Adolescent Institute, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647-Cerqueira César, São Paulo, SP, 05403-000, Brazil. .,Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
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Abstract
Background COVID-19 is an ongoing viral pandemic produced by SARS-CoV-2. In light of in vitro efficacy, several medications were repurposed for its management. During clinical use, many of these medications produced inconsistent results or had varying limitations. Objective The purpose of this literature review is to explain the variable efficacy or limitations of Lopinavir/Ritonavir, Remdesivir, Hydroxychloroquine, and Favipiravir in clinical settings. Method A study of the literature on the pharmacodynamics (PD), pharmacokinetics (PK), safety profile, and clinical trials through academic databases using relevant search terms. Results & discussion The efficacy of an antiviral drug against COVID-19 is associated with its ability to achieve therapeutic concentration in the lung and intestinal tissues. This efficacy depends on the PK properties, particularly protein binding, volume of distribution, and half-life. The PK and PD of the model drugs need to be integrated to predict their limitations. Conclusion Current antiviral drugs have varying pharmacological constraints that may associate with limited efficacy, especially in severe COVID-19 patients, or safety concerns.
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Aljubailah A, Alharbi WNO, Haidyrah AS, Al-Garni TS, Saeed WS, Semlali A, Alqahtani SMS, Al-Owais AA, Karami AM, Aouak T. Copolymer Involving 2-Hydroxyethyl Methacrylate and 2-Chloroquinyl Methacrylate: Synthesis, Characterization and In Vitro 2-Hydroxychloroquine Delivery Application. Polymers (Basel) 2021; 13:4072. [PMID: 34883576 PMCID: PMC8659029 DOI: 10.3390/polym13234072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
The Poly(2-chloroquinyl methacrylate-co-2-hydroxyethyl methacrylate) (CQMA-co-HEMA) drug carrier system was prepared with different compositions through a free-radical copolymerization route involving 2-chloroquinyl methacrylate (CQMA) and 2-hydroxyethyl methacrylate) (HEMA) using azobisisobutyronitrile as the initiator. 2-Chloroquinyl methacrylate monomer (CQMA) was synthesized from 2-hydroxychloroquine (HCQ) and methacryloyl chloride by an esterification reaction using triethylenetetramine as the catalyst. The structure of the CQMA and CQMA-co-HEMA copolymers was confirmed by a CHN elementary analysis, Fourier transform infra-red (FTIR) and nuclear magnetic resonance (NMR) analysis. The absence of residual aggregates of HCQ or HCQMA particles in the copolymers prepared was confirmed by a differential scanning calorimeter (DSC) and XR-diffraction (XRD) analyses. The gingival epithelial cancer cell line (Ca9-22) toxicity examined by a lactate dehydrogenase (LDH) assay revealed that the grafting of HCQ onto PHEMA slightly affected (4.2-9.5%) the viability of the polymer carrier. The cell adhesion and growth on the CQMA-co-HEMA drug carrier specimens carried out by the (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) (MTT) assay revealed the best performance with the specimen containing 3.96 wt% HCQ. The diffusion of HCQ through the polymer matrix obeyed the Fickian model. The solubility of HCQ in different media was improved, in which more than 5.22 times of the solubility of HCQ powder in water was obtained. According to Belzer, the in vitro HCQ dynamic release revealed the best performance with the drug carrier system containing 4.70 wt% CQMA.
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Affiliation(s)
- Abeer Aljubailah
- Department of Chemistry, College of Science, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh 13623, Saudi Arabia; (A.A.); (W.N.O.A.)
| | - Wafa Nazzal Odis Alharbi
- Department of Chemistry, College of Science, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh 13623, Saudi Arabia; (A.A.); (W.N.O.A.)
| | - Ahmed S. Haidyrah
- Nuclear and Radiological Control Unit, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia;
| | - Tahani Saad Al-Garni
- Chemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (T.S.A.-G.); (S.M.S.A.); (A.A.A.-O.); (A.M.K.)
| | - Waseem Sharaf Saeed
- Engineer Abdullah Bugshan Research Chair for Dental and Oral Rehabilitation, College of Dentistry, King Saud University, Riyadh 11545, Saudi Arabia
| | - Abdelhabib Semlali
- Groupe de Recherche en Écologie Buccale, Faculté de Médecin Dentaire, Université Laval, Quebec City, QC G1V 0A6, Canada;
| | - Saad M. S. Alqahtani
- Chemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (T.S.A.-G.); (S.M.S.A.); (A.A.A.-O.); (A.M.K.)
| | - Ahmad Abdulaziz Al-Owais
- Chemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (T.S.A.-G.); (S.M.S.A.); (A.A.A.-O.); (A.M.K.)
| | - Abdulnasser Mahmoud Karami
- Chemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (T.S.A.-G.); (S.M.S.A.); (A.A.A.-O.); (A.M.K.)
| | - Taieb Aouak
- Chemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (T.S.A.-G.); (S.M.S.A.); (A.A.A.-O.); (A.M.K.)
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Souza Botelho M, Bolfi F, Leite RGOF, Leite MSF, Banzato LR, Soares LT, Olivatti TOF, Mangolim AS, Oliveira FRK, Abbade LPF, Abbade JF, de Barros Almeida RAM, Simões Corrêa Galendi J, Thabane L, Dos Santos Nunes-Nogueira V. Systematic review and meta-analysis of the safety of chloroquine and hydroxychloroquine from randomized controlled trials on malarial and non-malarial conditions. Syst Rev 2021; 10:294. [PMID: 34736537 PMCID: PMC8567984 DOI: 10.1186/s13643-021-01835-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 10/11/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Despite the expectations regarding the effectiveness of chloroquine (CQ) and hydroxychloroquine (HCQ) for coronavirus disease (COVID-19) management, concerns about their adverse events have remained. OBJECTIVES The objective of this systematic review was to evaluate the safety of CQ and HCQ from malarial and non-malarial randomized clinical trials (RCTs). METHODS The primary outcomes were the frequencies of serious adverse events (SAEs), retinopathy, and cardiac complications. Search strategies were applied to MEDLINE, EMBASE, LILACS, CENTRAL, Scopus, and Trip databases. We used a random-effects model to pool results across studies and Peto's one-step odds ratio (OR) for event rates below 1%. Both-armed zero-event studies were excluded from the meta-analyses. We used the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate the certainty of evidence. RESULTS One hundred and six RCTs were included. We found no significant difference between CQ/HCQ and control (placebo or non-CQ/HCQ) in the frequency of SAEs (OR: 0.98, 95% confidence interval [CI]: 0.76-1.26, 33 trials, 15,942 participants, moderate certainty of evidence). However, there was a moderate certainty of evidence that CQ/HCQ increases the incidence of cardiac complications (RR: 1.62, 95% CI: 1.10-2.38, 16 trials, 9908 participants). No clear relationship was observed between CQ/HCQ and retinopathy (OR: 1.63, 95% CI: - 0.4-6.57, 5 trials, 344 participants, very low certainty of evidence). CONCLUSIONS CQ and HCQ probably do not increase SAEs, with low frequency of these adverse events on malarial and non-malarial conditions. However, they may increase cardiac complications especially in patients with COVID-19. No clear effect of their use on the incidence of retinopathy was observed. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020177818.
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Affiliation(s)
- Mayra Souza Botelho
- Department of Internal Medicine, São Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | - Fernanda Bolfi
- Department of Internal Medicine, São Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | | | | | - Luisa Rocco Banzato
- Department of Internal Medicine, São Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | - Luiza Teixeira Soares
- Department of Internal Medicine, São Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | | | - Amanda Sampaio Mangolim
- Department of Internal Medicine, São Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | | | - Luciana Patrícia Fernandes Abbade
- Department of Infectious Diseases, Dermatology, Imaging Diagnosis and Radiotherapy, São Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | - Joelcio Francisco Abbade
- Department of Gynecology and Obstetrics, São Paulo State University/UNESP, Medical School, Sao Paulo, Brazil
| | | | - Julia Simões Corrêa Galendi
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, St Joseph's Healthcare-Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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Perrella A, Orlando V, Trama U, Bernardi FF, Menditto E, Coscioni E. Pre-Exposure Prophylaxis with Hydroxychloroquine Does Not Prevent COVID-19 nor Virus Related Venous Thromboembolism. Viruses 2021; 13:v13102052. [PMID: 34696482 PMCID: PMC8537634 DOI: 10.3390/v13102052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 02/05/2023] Open
Abstract
Different and several public health strategies have been planned to reduce transmission of pandemic due to SARS-CoV-2 since it started. None drugs have been confirmed as able to prevent viral transmission. Hydroxychloroquine with its immunomodulatory properties has been proposed as potential anti-viral drug in particular for prevention once viral exposure has been happen or in first phases of infection. Furthermore, in several immunological systemic disease hydroxychloroquine was able to reduce the number of thrombotic complications. So, because COVID-19 was associated to immunological imbalance and to thrombotic complications, we retrospectively analyzed the rate of infection in those patients being under treatment with this drug during COVID-19 epidemic outbreak from 8 March until 28 April in particular comparing those with pre-exposure to this treatment and those that were not taking this medication before SARS-CoV-2 viral infections.
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Affiliation(s)
- Alessandro Perrella
- Hospital Health Direction, Infectious Disease Unit, Hospital A. Cardarelli, 80131 Naples, Italy
- Correspondence:
| | - Valentina Orlando
- CIRFF, Center of Pharmacoeconomics, University of Naples Federico II, 80131 Naples, Italy; (V.O.); (E.M.)
| | - Ugo Trama
- Regional Direction for Health Management, Pharmaceutical Unit, 80131 Naples, Italy; (U.T.); (F.F.B.)
| | - Francesca F. Bernardi
- Regional Direction for Health Management, Pharmaceutical Unit, 80131 Naples, Italy; (U.T.); (F.F.B.)
| | - Enrica Menditto
- CIRFF, Center of Pharmacoeconomics, University of Naples Federico II, 80131 Naples, Italy; (V.O.); (E.M.)
| | - Enrico Coscioni
- Division of Cardiac Surgery, AOU San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy;
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Bahramnezhad F, Ghorbani B, Ghaedrahamt M, Jamaati H. Coronavirus-disease-2019-induced antiphospholipid-like syndrome: a case report. J Med Case Rep 2021; 15:408. [PMID: 34321077 PMCID: PMC8318629 DOI: 10.1186/s13256-021-02966-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/17/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND This paper describes a case of antiphospholipid syndrome-like condition caused by coronavirus disease 2019. The medical community still faces many diagnostic and therapeutic challenges vis-à-vis coronavirus disease 2019. Ultimately, coronavirus disease 2019 is diagnosed on the basis of laboratory and radiological findings. Considering the high rate of mortality due to coagulation abnormalities and thrombosis among coronavirus disease 2019 patients, it is important to pay attention to the differential diagnoses of coronavirus disease 2019 and other diseases following thrombotic events. CASE DESCRIPTION The patient was a 56-year-old Iranian man who underwent coronary artery bypass graft surgery and mitral valve repair. During hospitalization, the patient showed an elevated level of anticardiolipin antibody (immunoglobulin G isotype), antiphospholipid antibodies, and thrombosis in the brachial artery of the left hand, based on which a differential diagnosis of antiphospholipid syndrome was made. However, ultimately, the coronavirus disease 2019 polymerase chain reaction test and computed tomography scan of the lungs showed that the patient had coronavirus disease 2019. CONCLUSION According to the few studies performed on coronavirus disease 2019 patients, elevated levels of the isotypes of antiphospholipid antibodies in coronavirus disease 2019 patients create conditions similar to antiphospholipid syndrome, which, in the absence of reliable coronavirus disease 2019 testing, can lead to misdiagnosis and consequently delayed or improper treatment. Therefore, to provide timely and appropriate treatment, it is important to pay attention to differential diagnosis.
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Affiliation(s)
- Fatemeh Bahramnezhad
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- Spiritual Health Group, Research Center of Quran, Hadith and Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Banafsheh Ghorbani
- Student Research Committee, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Meysam Ghaedrahamt
- Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Jamaati
- Chronic Respiratory Diseases Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Erkan D. Expert Perspective: Management of Microvascular and Catastrophic Antiphospholipid Syndrome. Arthritis Rheumatol 2021; 73:1780-1790. [PMID: 34114366 DOI: 10.1002/art.41891] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Doruk Erkan
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
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48
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Edington FLB, Gadellha SR, Santiago MB. Safety of treatment with chloroquine and hydroxychloroquine: A ten-year systematic review and meta-analysis. Eur J Intern Med 2021; 88:63-72. [PMID: 33832827 DOI: 10.1016/j.ejim.2021.03.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To estimate the incidence rate ratio (IRR) of adverse events (AE) in chloroquine or hydroxychloroquine users. METHODS We systematically reviewed randomized controlled trials (RCTs), using MEDLINE (2010-2020) and EMBASE (2010-2020) databases, reporting AE in chloroquine or hydroxychloroquine users during treatment for lupus, rheumatoid arthritis, malaria and COVID-19. The protocol for this systematic review is registered at the PROSPERO database (CRD42020197938). The quality of the included studies was assessed using the Cochrane risk-of-Bias tool and relevant data were extracted though a customized data collection form, independently, by two authors. The IRR of AE was estimated using a random-effect model meta-analysis and heterogeneity was evaluated by T2 and I2. Subgroup analysis was performed, and publication bias was assessed by funnel-plot. RESULTS Forty-six RCTs met our eligibility criteria and were included in our analysis (23132 patients). There was not a single death attributed to chloroquine or hydroxychloroquine use in the included RCTs. The IRR of general AE during antimalarial use was 1.15 [CI 95% 1.01-1.31]. COVID-19 patients treated with either antimalarial presented an 83% and 165% higher risk of developing general and gastrointestinal AE, respectively, in comparison with controls. The use of antimalarial increased the risk of developing dermatological AE by 92% in malarial studies and reduced by 65% in lupus studies. We did not find a significatively higher risk of cardiovascular nor ophthalmological AE in antimalarial users. CONCLUSIONS Our data reinforces that chloroquine and hydroxychloroquine have a good safety profile though caution is advised when using higher than usual doses in hospitalized COVID-19 patients.
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Affiliation(s)
- Fernando Luiz Barros Edington
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil; Universidade Estadual de Santa Cruz, Ilhéus, Bahia, Brazil.
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Ugarte A, Garcia de Bustos A, Ruiz-Arruza I, Soto-Peleteiro A, Martin-Iglesias D, Gonzalez-Echavarri C, Ruiz-Irastorza G. ANTIPHOSPHOLIPID ANTIBODIES DO NOT PREDICT DAMAGE IN SLE PATIENTS IN THE XXI CENTURY. AN OBSERVATIONAL STUDY FROM THE LUPUS-CRUCES COHORT. Rheumatology (Oxford) 2021; 61:249-257. [PMID: 33769455 DOI: 10.1093/rheumatology/keab307] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To compare the influence of antiphospholipid antibodies (aPL) on global and cardiovascular damage in patients with systemic lupus erythematosus (SLE) diagnosed before and after year 2000. METHODS 286 patients from the Lupus-Cruces cohort with a minimum follow-up of 5 years, divided into two sub-cohorts according to the date of diagnosis, before 2000 (<2000) and from 2000 on (≥2000). We compared the mean SDI score and global and cardiovascular damage-free survival rates in the presence/absence of aPL in both sub-cohorts. Variables potentially modulating damage among aPL-positive patients were analysed. RESULTS The sub-cohorts were comparable for demographic and lupus-related variables except for treatment variables: the ≥2000 sub-cohort received lower doses of prednisone and more hydroxychloroquine, low-dose aspirin, statins, immunosuppressive agents and Vitamin D. aPL-positive patients in the <2000, but not in the ≥2000 sub-cohort, accrued more damage compared with aPL-negative. In the <2000 sub-cohort, the adjusted HRs for global and cardiovascular damage in aPL-positive vs. aPL-negative patients were 1.98 (95% CI 1.24-3.14) and 9.3 (95% CI 3.24-26.92), respectively. No differences in damage were seen between aPL-positive and aPL-negative patients in the ≥2000 sub-cohort. Hypertension (HR 4.64, 95%CI 1.33-16.19), lupus anticoagulant (HR 3.85, 95%CI 1.1-13.41) and the number of months on hydroxychloroquine (HR 0.97, 95%CI 0.95-0.99) were independent predictors of vascular damage in the combined analysis of all aPL-positive patients. CONCLUSION The effects of aPL on damage accrual in SLE patients have been reduced over the last years. The widespread use of hydroxychloroquine and a better thromboprophylaxis are likely causing this change.
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Affiliation(s)
- Amaia Ugarte
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain
| | | | - Ioana Ruiz-Arruza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain.,University of The Basque Country, Bizkaia, The Basque Country, Spain
| | - Adriana Soto-Peleteiro
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain
| | - Daniel Martin-Iglesias
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain
| | - Cristina Gonzalez-Echavarri
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Bizkaia, The Basque Country, Spain.,University of The Basque Country, Bizkaia, The Basque Country, Spain
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Tektonidou MG, Papassotiriou I, Sfikakis PP. Growth Differentiation Factor 15 (GDF-15) as potential cardiovascular risk biomarker in Antiphospholipid Syndrome. Rheumatology (Oxford) 2021; 61:394-399. [PMID: 33748838 DOI: 10.1093/rheumatology/keab277] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE An interplay between thrombo-inflammatory and atherogenic mechanisms is recognized in cardiovascular disease pathogenesis (CVD) in antiphospholipid syndrome (APS). Herein, we examine associations of growth differentiation factor-15 (GDF-15), a pro-inflammatory cytokine identified as potent CVD risk biomarker in the general population, with subclinical atherosclerosis in APS. METHODS We measured plasma GDF-15 levels by an electrochemiluminescence immunoassay (cut-off 1200 pg/mL) and examined carotid intima-media thickness (IMT) and the presence of carotid and femoral plaques using vascular ultrasound in 80 patients with APS (44 primary, 36 systemic lupus erythematosus (SLE)/APS) and 40 healthy controls. We calculated the aGAPSSCVD, a revised adjusted Global APS Score (aGAPSS) to predict CVD, including lupus anticoagulant, anticardiolipin and anti-beta2glycoprotein-I antibodies, and hypertension, dyslipidemia, obesity, diabetes and smoking. RESULTS GDF-15 levels were higher in APS patients vs. controls adjusting for age and gender (absolute difference: 281 (95% CI: 141-421) pg/mL, p < 0.001). GDF-15 levels ≥1200 pg/mL were associated with higher mean IMT of right and left carotid (beta coefficient 0.068 (95% CI: 0.020, 0.116), p = 0.006) compared with GDF-15 levels <1200 pg/mL. GDF-15 was independently associated with mean IMT adjusting for gender and aGAPSSCVD (beta coefficient 0.059 (95% CI: 0.008-0.110, p = 0.024), and additionally for statin (p = 0.025) and hydroxychloroquine use (p = 0.011). GDF-15 levels ≥1200 pg/mL were associated with 2.4 higher odds for atherosclerotic plaques (OR = 2.438 (95% CI: 0.906, 6.556), p = 0.078), while this effect reduced adding more covariates in the model. CONCLUSION GDF-15 is independently associated with subclinical atherosclerosis in APS patients suggesting its potential role in CVD risk stratification in APS.
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Affiliation(s)
- Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, Laiko Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Papassotiriou
- Department of Clinical Biochemistry, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, Laiko Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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