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Legge AC, Hanly JG. Recent advances in the diagnosis and management of neuropsychiatric lupus. Nat Rev Rheumatol 2024:10.1038/s41584-024-01163-z. [PMID: 39358609 DOI: 10.1038/s41584-024-01163-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2024] [Indexed: 10/04/2024]
Abstract
Neuropsychiatric manifestations of systemic lupus erythematosus (SLE) are common and frequently associated with a substantial negative impact on health outcomes. The pathogenesis of neuropsychiatric SLE (NPSLE) remains largely unknown, but a single pathogenic mechanism is unlikely to be responsible for the heterogeneous array of clinical manifestations, and a combination of inflammatory and ischaemic mechanistic pathways have been implicated. Currently, valid and reliable biomarkers for the diagnosis of NPSLE are lacking, and differentiating NPSLE from nervous system dysfunction not caused by SLE remains a major challenge for clinicians. However, correct attribution is essential to ensure timely institution of appropriate treatment. In the absence of randomized clinical trials on NPSLE, current treatment strategies are derived from clinical experience with different therapeutic modalities and their efficacy in the management of other manifestations of SLE or of neuropsychiatric disease in non-SLE populations. This Review describes recent advances in the understanding of NPSLE that can inform diagnosis and management, as well as unanswered questions that necessitate further research.
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Affiliation(s)
- Alexandra C Legge
- Division of Rheumatology, Department of Medicine, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - John G Hanly
- Division of Rheumatology, Department of Medicine, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
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Luo L, Cai Q, Liu X, Hou Y, Li C. Risk factors of first thrombosis in obstetric antiphospholipid syndrome. Lupus Sci Med 2024; 11:e001044. [PMID: 38176700 PMCID: PMC10773425 DOI: 10.1136/lupus-2023-001044] [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: 09/07/2023] [Accepted: 12/09/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE There is limited evidence on long-term thrombosis risk in patients with obstetric antiphospholipid syndrome (OAPS). This study aimed to investigate the clinical features and risk factors associated with the first thrombosis in patients with isolated OAPS. METHODS Data from patients with isolated OAPS were collected. All patients were followed up until the first thrombotic event during or after delivery or until the end of the study. Logistic regression analysis identified independent risk factors associated with the first thrombosis in patients with isolated OAPS. RESULTS The study enrolled 186 patients with OAPS. During a mean 5.4-year follow-up, 11 (5.9%) patients experienced thrombotic events. Multivariate binary logistic regression analysis revealed that triple-positive antiphospholipid antibodies (aPLs, OR=11.662, 95% CI=2.117 to 64.243, p=0.005) and hypocomplementemia (OR=9.047, 95% CI=1.530 to 53.495, p=0.015) were identified as independent risk factors for the first thrombosis in OAPS, after adjustment for low-dose aspirin and hydroxychloroquine. CONCLUSIONS Triple-positive aPLs and hypocomplementemia are risk factors for the first thrombosis in patients with OAPS.
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Affiliation(s)
- Liang Luo
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- Department of Chinese Medicine, the People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Qingmeng Cai
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Xiangjun Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Yuke Hou
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
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Depietri L, Veropalumbo MR, Leone MC, Ghirarduzzi A. Antiphospholipid Syndrome: State of the Art of Clinical Management. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07496-3. [PMID: 37572208 DOI: 10.1007/s10557-023-07496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/14/2023]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder clinically characterized by recurrent arterial and venous thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies. Currently, treatment is mainly focused on anticoagulation, but therapies targeting mechanisms involved in APS autoimmune pathogenesis could play an important role in specific settings. An evidence-based therapeutic approach is limited by the broad clinical spectrum of the syndrome and the nature of a "rare disease" that makes it difficult to carry out well-designed prospective studies. Vitamin K antagonists (AVK), notably warfarin, are the standard treatment for preventing recurrent venous thrombosis and perhaps also arterial thrombosis. Direct oral anticoagulants (DOACs) are not recommended at least in patients with triple positivity APS. Treatment options for the prevention of pregnancy complications in obstetric APS, as combined use of aspirin and heparin, low-dose prednisolone, hydroxychloroquine, intravenous immunoglobulin (IVIG), may improve pregnancy outcome. The catastrophic antiphospholipid syndrome (CAPS) is the most severe form of APS with acute multiple organ involvement and small vessel thrombosis. Glucocorticoids, heparin, plasma exchange or IVIG, rituximab, or eculizumab must be added to concurrent treatment of precipitating factors (e.g. infections) as rescue therapies. Finally, it has been observed that SARS COV2 infection may produce vascular complications mimicking the clinical and pathophysiological features of APS and particularly of CAPS. From this point of view, attention has been focused on the "protective" role of anticoagulant therapy in preventing thrombotic complication when these clinical conditions coexist.
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Affiliation(s)
- Luca Depietri
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Maria Rosaria Veropalumbo
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Maria Cristina Leone
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Angelo Ghirarduzzi
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
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Lipari A, Sorrentino S, Tamburini C, Castaman G, Prisco D, De Candia E. Bleeding and thrombotic events in a patient with lupus anticoagulant-associated hypoprothrombinemia and antiphospholipid antibody syndromes: managing hemostasis between Scylla and Charybdis. Intern Emerg Med 2023; 18:1233-1238. [PMID: 37165299 DOI: 10.1007/s11739-023-03292-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/22/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Alice Lipari
- Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy
| | - Silvia Sorrentino
- Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy
| | - Carlo Tamburini
- SOD Medicina Interna Interdisciplinare, AOU Careggi, Firenze, Italy
| | - Giancarlo Castaman
- Dipartimento di Oncologia, AOU Careggi, Centro di Malattie Emorragiche e Trombotiche, Firenze, Italy
| | - Domenico Prisco
- SOD Medicina Interna Interdisciplinare, AOU Careggi, Firenze, Italy
- Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Firenze, Italy
| | - Erica De Candia
- Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy.
- Dipartimento di Medicina e Chirurgia Traslazionale, Universita Cattolica del Sacro Cuore, Roma, Italy.
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Abstract
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
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Primary Anti-Phospholipid Antibody Syndrome: Real-World Defining Features of Rethrombosis in the Course of Disease. Int J Rheumatol 2022; 2022:7331586. [PMID: 36405382 PMCID: PMC9671724 DOI: 10.1155/2022/7331586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/12/2022] Open
Abstract
Objective We aimed to identify features that allow differentiation of primary antiphospholipid syndrome (PAPS) patients that suffer recurrent thrombotic events (RTE) despite anticoagulation, from the other diagnosed PAPS patients. Methods This was an exploratory study of anticoagulated PAPS patients attending an Autoimmune Diseases Unit (1998-2018). From 2016, anti-phospholipid antibodies and lupus anticoagulant were determined for each patient at consecutive visits, collected together with retrospective clinical characteristics, laboratory, and therapeutic markers and compared according to the occurrence of thrombotic events during follow-up. Results Overall, two thirds of the patients were female, 93% were Caucasian, with a median age of 40 years at diagnosis, for a median time of 11.5 years in follow-up. Out of 54 patients, 10 were identified with RTE. There were no significant differences among the RTE and non-RTE patients as far as classical risk factors for clotting disorders. The RTE group was characterized by a higher proportion of younger patients, male sex and positivity for all laboratory markers, and initially and over follow-up as well as a sustained high-risk profile based on APS laboratory markers. Anticardiolipin IgG at onset was the only statistically significant marker of the RTE group. At the end of follow-up, consistent reversion to negative status was a rare event, observed in 20% of RTE vs. 25% of non-RTE patients. Conclusions Despite therapy, we were able to identify features associated to thrombotic events in patients with PAPS. Prospectively regular clinical and laboratory monitoring might be warranted in order to treat APS more assertively.
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Tiperneni R, Tayyeb M, Fichadiya H, Al-Alwan A, Khalid F, Rajamohan A. When Blood Is Being Difficult: Clotting and Bleeding in a Patient With Antiphospholipid Antibody Syndrome and Supratherapeutic International Normalized Ratio. Cureus 2022; 14:e25659. [PMID: 35677737 PMCID: PMC9167035 DOI: 10.7759/cureus.25659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 11/05/2022] Open
Abstract
Venous thromboembolism includes deep venous thrombosis (DVT) and pulmonary embolism and is the most common cardiovascular disease after coronary artery disease and stroke. Antiphospholipid syndrome (APS) is an autoimmune disorder that is characterized by venous or arterial thrombosis with laboratory evidence of antiphospholipid antibodies. Long-term anticoagulation therapy is required to prevent recurrent DVTs, embolisms, and thrombosis-related complications. Treatment options include vitamin K antagonists, subcutaneous low-molecular-weight heparin, unfractionated heparin, or direct oral anticoagulants. Warfarin (a vitamin K antagonist) remains the mainstay of treatment in APS patients with a prior history of DVT and is associated with elevation of the international normalized ratio which is often used as a marker for therapy appropriateness and warfarin dosing. Here, we describe a unique case of a 65-year-old female with APS on warfarin (given prior lower extremity DVT) presenting with bleeding/hematoma in the left breast and a clot in the left upper extremity.
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Yang R, Zhang J, Zhang L, Liu Y, Guo Q. Combined detection of anticardiolipin and anti-β2-glycoprotein 1 antibodies may predict pregnancy outcome. Am J Transl Res 2022; 14:1750-1756. [PMID: 35422959 PMCID: PMC8991117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/24/2020] [Indexed: 06/14/2023]
Abstract
Antiphospholipid syndrome (APS) is a typical non-inflammatory autoimmune disease that is common in young women. It is characterized by the presence of the anti-cardiolipin antibody (ACA) and anti-β2 glycoprotein 1 (anti-β2-GP1) antibody and is associated with a high risk of arteriovenous thrombosis. We measured the expression of ACA and anti-β2-GP1 antibodies in the serum of pregnant women early in their pregnancy, and analyzed the pregnancy outcome of the primigravidas who were positive for both the antibodies, so as to evaluate the efficacy of the combined determination in predicting pregnancy outcome. A total of 102 pregnant women who visited the Hebei General Hospital from January 2014 to December 2017 were enrolled in the study. The serum levels of ACA and anti-β2-GP1 antibodies were determined in all the enrolled pregnant women using the enzyme-linked immunosorbent assay (ELISA) method and the correlation between positive ACA/anti-β2-GP1 antibody and the adverse pregnancy outcomes was analyzed. Meanwhile, the difference in the pregnancy outcomes between patients who were positive for ACA only, for anti-β2-GP1 only and for both of the two antibodies was also investigated. The incidence of adverse pregnancy outcomes of pregnant women who were positive for both the ACA and the anti-β2-GP1 antibodies (48.87%) was higher than that of those positive for ACA only (28.67%) and those positive for anti-β2-GP1 only (36.66%). The positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of the combined determination of the two predictors was 81.75%, 95.84%, 88.37% and 95.92%, respectively. The combined determination of ACA and anti-β2-GP1 antibodies early in pregnancy may predict the occurrence of pregnancy outcome, with superiority over either of the two predictors alone.
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Affiliation(s)
- Rongjuan Yang
- The 7th Obstertrics Department, Shijiazhuang Gynecological & Obstetrical HospitalShijiazhuang 050000, Hebei, China
| | - Jiajia Zhang
- The 7th Obstertrics Department, Shijiazhuang Gynecological & Obstetrical HospitalShijiazhuang 050000, Hebei, China
| | - Limei Zhang
- The 7th Obstertrics Department, Shijiazhuang Gynecological & Obstetrical HospitalShijiazhuang 050000, Hebei, China
| | - Yongli Liu
- The 7th Obstertrics Department, Shijiazhuang Gynecological & Obstetrical HospitalShijiazhuang 050000, Hebei, China
| | - Qing Guo
- Obstertrics Department, Shijiazhuang Gynecological & Obstetrical HospitalShijiazhuang 050000, Hebei, China
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Zhao Z, Zhang X, Zhang H, Shan X, Bai M, Wang Z, Yang F, Zhang H, Kan Q, Sun B, Sun J, He Z, Luo C. Elaborately Engineering a Self-Indicating Dual-Drug Nanoassembly for Site-Specific Photothermal-Potentiated Thrombus Penetration and Thrombolysis. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2104264. [PMID: 34802198 PMCID: PMC8811805 DOI: 10.1002/advs.202104264] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Indexed: 05/19/2023]
Abstract
Thrombotic cardio-cerebrovascular diseases seriously threaten human health. Currently, conventional thrombolytic treatments are challenged by the low utilization, inferior thrombus penetration, and high off-target bleeding risks of most thrombolytic drugs, resulting in unsatisfactory treatment outcomes. Herein, it is proposed that these challenges can be overcome by precisely integrating the conventional thrombolytic strategy with photothermal therapy. After co-assembly engineering optimization, a fibrin-targeting peptide-decorated nanoassembly of DiR (a photothermal probe) and ticagrelor (TGL, an antiplatelet drug) is prepared for thrombus-homing delivery, abbreviated as FT-DT NPs. The elaborately engineered nanoassembly shows multiple advantages, including simple preparation with high drug co-loading capacity, synchronous delivery of two drugs with long systemic circulation, thrombus-targeted accumulation with self-indicating function, as well as photothermal-potentiated thrombus penetration and thrombolysis with high therapeutic efficacy. As expected, FT-DT NPs not only show bright fluorescence signals in the embolized vessels, but also perform photothermal/antiplatelet synergistic thrombolysis in vivo. This study offers a simple and versatile co-delivery nanoplatform for imaging-guided photothermal/antiplatelet dual-modality thrombolysis.
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Affiliation(s)
- Zhiqiang Zhao
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Xuanbo Zhang
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Hongyuan Zhang
- School of Life Science and BiopharmaceuticsShenyang Pharmaceutical UniversityShenyang110016P. R. China
| | - Xinzhu Shan
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Meiyu Bai
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Zhe Wang
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Fujun Yang
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Haotian Zhang
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Qiming Kan
- School of Life Science and BiopharmaceuticsShenyang Pharmaceutical UniversityShenyang110016P. R. China
| | - Bingjun Sun
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Jin Sun
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Zhonggui He
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
| | - Cong Luo
- Department of PharmaceuticsWuya College of InnovationShenyang Pharmaceutical UniversityShenyangLiaoning110016P. R. China
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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: 6] [Impact Index Per Article: 3.0] [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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Guan Q, Dou H. Thrombus-Targeting Polymeric Nanocarriers and Their Biomedical Applications in Thrombolytic Therapy. Front Physiol 2021; 12:763085. [PMID: 34916956 PMCID: PMC8669757 DOI: 10.3389/fphys.2021.763085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/08/2021] [Indexed: 01/08/2023] Open
Abstract
Due to the high morbidity and mortality of cardiovascular diseases, there is an urgent need for research on antithrombotic strategies. In view of the short half-life, insufficient drug penetration, poor targeting capabilities, and hemorrhagic side-effects of traditional thrombus treatment methods, the combination of thrombolytic therapy and nanocarriers brought by the development of nanotechnology in recent years may provide effective solutions for these undesirable side-effects caused by insufficient targeting. Polymeric nanocarriers, based on macromolecules and various functional groups, can connect specific targeting molecules together through chemical modification to achieve the protection and targeted delivery of thrombolytic drugs. However, simple chemical molecular modifications may be easily affected by the physiological environment encountered in the circulatory system. Therefore, the modification of nanocarriers with cell membranes can provide camouflage to these platforms and help to extend their circulation time while also imparting them with the biological functions of cell membranes, thus providing them with precise targeting capabilities, among which the most important is the biological modification of platelet membranes. In addition, some nanoparticles with their own therapeutic functions have also been developed, such as polypyrrole, which can exhibit a photothermal effect to induce thrombolysis. Herein, combined with the mechanism of thrombosis and thrombolysis, we outline the recent advances achieved with thrombus-targeting nanocarriers with regard to thrombosis treatment. On this basis, the design considerations, advantages, and challenges of these thrombolytic therapies in clinical transformation are discussed.
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Affiliation(s)
| | - Hongjing Dou
- State Key Laboratory of Metal Matrix Composites, School of Materials Science and Engineering, Shanghai Jiao Tong University, Shanghai, China
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Yan X, Wang D, Yan P, Li H. Low molecular weight heparin or LMWH plus aspirin in the treatment of unexplained recurrent miscarriage with negative antiphospholipid antibodies: A meta-analysis of randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2021; 268:22-30. [PMID: 34794071 DOI: 10.1016/j.ejogrb.2021.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/22/2021] [Accepted: 10/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Unexplained recurrent miscarriage (uRM) has caused serious distress to women of childbearing age, and effective treatment is particularly important. The aim of this meta-analysis is to compare the efficacy of low molecular weight heparin (LMWH) and LMWH combined with aspirin for uRM. METHODS Databases including PubMed, Web of Science, Embase, Scopus and the Cochrane Library databases were electronically searched to identify randomized controlled trials that reported the LMWH or LMWH combined with aspirin for women with uRM and negative antiphospholipid antibodies (aPL). The retrieval time is limited from inception to June 2021. Two reviewers independently screened literature, extracted data, and assessed risk bias of included studies. Meta-analysis was performed by using STATA 12.0 software. RESULTS A total of 7 studies involving 1849 patients were included. The meta-analysis results showed that compared with the control group, both LMWH and LMWH + aspirin interventions showed no substantial influence on miscarriage rate (LMWH: RR = 0.69, 95%CI: 0.34-1.39, P = 0.293, LMWH + aspirin: RR = 0.62, 95%CI: 0.30-1.27, P = 0.19) and the occurrence of pre-eclampsia (LMWH: RR = 1.1, 95%CI: 0.53-2.31, P = 0.792; LMWH + aspirin: RR = 1.49, 95%CI: 0.25-8.79, P = 0.662). LMWH therapy had no influence on the live births (RR = 0.99, 95%CI: 0.92-1.06, P = 0.72). Subgroup analysis showed that enoxaparin is not effective in women with uRM and negative aPL (miscarriage rate: RR = 0.82, 95%CI: 0.31-2.19, P = 0.695; pre-eclampsia: RR = 1.03, 95%CI: 0.46-2.33, P = 0.936). CONCLUSIONS LMWH and LMWH combined with aspirin therapy cannot improve the pregnancy outcome of women with uRM and negative aPL. However, the above conclusions are still required to be verified through more RCTs due to the limited quantity of included studies.
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Affiliation(s)
- Xiaoli Yan
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dan Wang
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ping Yan
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hongyu Li
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Calcaterra I, Ambrosino P, Vitelli N, Lupoli R, Orsini RC, Chiurazzi M, Maniscalco M, Di Minno MND. Risk Assessment and Antithrombotic Strategies in Antiphospholipid Antibody Carriers. Biomedicines 2021; 9:biomedicines9020122. [PMID: 33513790 PMCID: PMC7911177 DOI: 10.3390/biomedicines9020122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/31/2022] Open
Abstract
Antiphospholipid antibodies (aPL) are a cluster of autoantibodies directed against plasma proteins with affinity for membrane phospholipids. The most frequently tested aPL are lupus anticoagulant (LA), anti-cardiolipin antibodies (aCL), and anti-β2-glycoprotein I antibodies (anti-β2GPI). aPL play a key pathogenic role in the development of the antiphospholipid syndrome (APS), a systemic autoimmune disease characterized by recurrent thrombotic and/or pregnancy complications in patients with persistent aPL. However, aPL positivity is occasionally documented in patients with no previous history of thrombotic or pregnancy morbidity. LA activity, multiple aPL positivity, high-titer aPL, and a concomitant systemic autoimmune disease are recognized risk factors for future thrombotic events in asymptomatic carriers. Moreover, an accelerated atherosclerosis with increased cardiovascular (CV) risk has also been associated with aPL positivity, thus exposing aPL carriers to fatal complications and chronic disability requiring cardiac rehabilitation. Overall, an accurate risk stratification is recommended for aPL-positive subjects in order to prevent both venous and arterial thrombotic complications. In this review, we provide an overview of the main antithrombotic and risk assessment strategies in aPL carriers.
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Affiliation(s)
- Ilenia Calcaterra
- Department of Clinical Medicine and Surgery, Faculty of Medicine and Surgery, Federico II University, 80131 Naples, Italy; (I.C.); (N.V.); (R.C.O.); (M.C.)
| | - Pasquale Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy;
- Correspondence: ; Tel./Fax: +39-0824-909458
| | - Nicoletta Vitelli
- Department of Clinical Medicine and Surgery, Faculty of Medicine and Surgery, Federico II University, 80131 Naples, Italy; (I.C.); (N.V.); (R.C.O.); (M.C.)
| | - Roberta Lupoli
- Department of Molecular Medicine and Medical Biotechnology, Faculty of Medicine and Surgery, Federico II University, 80131 Naples, Italy;
| | - Roberta Clara Orsini
- Department of Clinical Medicine and Surgery, Faculty of Medicine and Surgery, Federico II University, 80131 Naples, Italy; (I.C.); (N.V.); (R.C.O.); (M.C.)
| | - Martina Chiurazzi
- Department of Clinical Medicine and Surgery, Faculty of Medicine and Surgery, Federico II University, 80131 Naples, Italy; (I.C.); (N.V.); (R.C.O.); (M.C.)
| | | | - Matteo Nicola Dario Di Minno
- Department of Translational Medical Sciences, Faculty of Medicine and Surgery, Federico II University, 80131 Naples, Italy;
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Bala MM, Celinska-Lowenhoff M, Szot W, Padjas A, Kaczmarczyk M, Swierz MJ, Undas A. Antiplatelet and anticoagulant agents for secondary prevention of stroke and other thromboembolic events in people with antiphospholipid syndrome. Cochrane Database Syst Rev 2020; 10:CD012169. [PMID: 33045766 PMCID: PMC8094585 DOI: 10.1002/14651858.cd012169.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial or venous thrombosis (or both), and/or pregnancy morbidity in association with the presence of antiphospholipid antibodies. The prevalence of APS is estimated at 40 to 50 cases per 100,000 people. The most common sites of thrombosis are cerebral arteries and deep veins of the lower limbs. People with a definite APS diagnosis have an increased lifetime risk of recurrent thrombotic events. OBJECTIVES To assess the effects of antiplatelet (AP) or anticoagulant agents, or both, for the secondary prevention of recurrent thrombosis, particularly ischemic stroke, in people with APS. SEARCH METHODS We last searched the MEDLINE, Embase, CENTRAL, Cochrane Stroke Group Trials Register, and ongoing trials registers on 22 November 2019. We checked reference lists of included studies, systematic reviews, and practice guidelines. We also contacted experts in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated any anticoagulant or AP agent, or both, in the secondary prevention of thrombosis in people with APS, according to the criteria valid when the study took place. We did not include studies specifically addressing women with obstetrical APS. DATA COLLECTION AND ANALYSIS Pairs of review authors independently worked on each step of the review, following Cochrane methods. We summarized the evidence using the GRADE approach. MAIN RESULTS We identified eight studies including 811 participants that compared different AP or anticoagulant agents. NOAC (non-VKA oral anticoagulant: rivaroxaban 15 or 20 mg/d) versus standard-dose VKA (vitamin K antagonist: warfarin at moderate International Normalized Ratio [INR] - 2.5) or adjusted [INR 2.0-3.0] dose): In three studies there were no differences in any thromboembolic event (including death) and major bleeding (moderate-certainty evidence), but an increased risk of stroke (risk ratio [RR] 14.13, 95% confidence interval [CI] 1.87 to 106.8; moderate-certainty evidence). One of the studies reported a small benefit of rivaroxaban in terms of quality of life at 180 days measured as health state on Visual Analogue Scale (mean difference [MD] 7 mm, 95% CI 2.01 to 11.99; low-certainty evidence), but not measured as health utility on a scale from 0 to 1 (MD 0.04, 95% CI -0.02 to 0.10; low-certainty evidence). High-dose VKA (warfarin with a target INR of 3.1 to 4.0 [mean 3.3] or 3.5 [mean 3.2]) versus standard-dose VKA (warfarin with a target INR of 2.0 to 3.0 [mean 2.3] or 2.5 [mean 2.5]): In two studies there were no differences in the rates of thrombotic events and major bleeding (RR 2.22, 95% CI 0.79 to 6.23, low-certainty evidence), but an increased risk of minor bleeding in one study during a mean of 3.4 years (standard deviation [SD] 1.2) of follow-up (RR 2.55, 95% CI 1.07 to 6.07). In both trials there was evidence of a higher risk of any bleeding (hazard ratio [HR] 2.03 95% CI 1.12 to 3.68; low-certainty evidence) in the high-dose VKA group, and for this outcome (any bleeding) the incidence is not different, only the time to event is showing an effect. Standard-dose VKA plus a single AP agent (warfarin at a target INR of 2.0 to 3.0 plus aspirin 100 mg/d) versus standard-dose VKA (warfarin at a target INR of 2.0 to 3.0): One high-risk-of-bias study showed an increased risk of any thromboembolic event with combined treatment (RR 2.14, 95% CI 1.04 to 4.43; low-certainty evidence) and reported on major bleeding with five cases in the combined treatment group and one case in the standard-dose VKA treatment group, resulting in RR 7.42 (95% CI 0.91 to 60.7; low-certainty evidence) and no differences for secondary outcomes (very low- to low-certainty evidence). Single/dual AP agent and standard-dose VKA (pooled results): Two high-risk-of-bias studies compared a combination of AP and VKA (aspirin 100 mg/d plus warfarin or unspecified VKA at a target INR of 2.0 to 3.0 or 2.0 to 2.5) with a single AP agent (aspirin 100 mg/d), but did not provide any conclusive evidence regarding the effects of those drugs in people with APS (very low-certainty evidence). One of the above-mentioned studies was a three-armed study that compared a combination of AP and VKA (aspirin 100 mg/d plus warfarin at a target INR of 2.0 to 2.5) with dual AP therapy (aspirin 100 mg/d plus cilostazol 200 mg/d) and dual AP therapy (aspirin 100 mg/d plus cilostazol 200 mg/d) versus a single AP treatment (aspirin 100 mg/d). This study reported on stroke (very low-certainty evidence) but did not report on any thromboembolic events, major bleeding, or any secondary outcomes. We identified two ongoing studies and three studies are awaiting classification. AUTHORS' CONCLUSIONS The evidence identified indicates that NOACs compared with standard-dose VKAs may increase the risk of stroke and do not appear to alter the risk of other outcomes (moderate-certainty evidence). Using high-dose VKA versus standard-dose VKA did not alter the risk of any thromboembolic event or major bleeding but may increase the risk of any form of bleeding (low-certainty evidence). Standard-dose VKA combined with an AP agent compared with standard-dose VKA alone may increase the risk of any thromboembolic event and does not appear to alter the risk of major bleeding or other outcomes (low-certainty evidence). The evidence is very uncertain about the benefit or harm of using standard-dose VKA plus AP agents versus single or dual AP therapy, or dual versus single AP therapy, for the secondary prevention of recurrent thrombosis in people with APS (very low-certainty evidence).
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Affiliation(s)
- Malgorzata M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
- Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Celinska-Lowenhoff
- 2nd Department of Internal Medicine, Department of Allergy and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Szot
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Padjas
- 2nd Department of Internal Medicine, Department of Allergy and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Kaczmarczyk
- Systematic Reviews Unit - Polish Cochrane Branch, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz J Swierz
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
- Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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17β-Estradiol Promotes Proinflammatory and Procoagulatory Phenotype of Innate Immune Cells in the Presence of Antiphospholipid Antibodies. Biomedicines 2020; 8:biomedicines8060162. [PMID: 32549383 PMCID: PMC7345022 DOI: 10.3390/biomedicines8060162] [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: 05/20/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 11/17/2022] Open
Abstract
Antiphospholipid syndrome (APS) is the most common cause of acquired thrombophilia and recurrent spontaneous miscarriages associated with extended persistence of antiphospholipid antibodies (aPL). How circulating aPL and high-17β-estradiol (E2) environment contribute to the pregnancy complications in APS is poorly defined. Therefore, we aimed to analyse whether E2 could be responsible for the immune cell hyperactivation in aPL- positive (lupus anticoagulant, anti-cardiolipin, anti-β2-glycoprotein) in women. For this, peripheral blood mononuclear cells (PBMCs) from 14 aPL- positive and 13 aPL- negative women were cultured in the presence or absence of E2, LPS or E2+LPS and cell immunophenotype and cytokine release were analysed. In the aPL+ group, E2 presence markedly increased the percentage of NK cells positive for CD69 (p < 0.05), monocytes positive for tissue factor (TF, CD142) (p < 0.05), and B cells expressing PD-L1 (p < 0.05), as well as the elevated production of IL-1β comparing to aPL- women (p < 0.01). Regardless of aPL positivity, E2 augmented the procoagulatory response elicited by LPS in monocytes. Our findings show the ability of E2 to promote proinflammatory and procoagulatory phenotype of innate immune cells in individuals with aPL positivity. Our data highlights the significant impact of female hormones on the activation of immune cells in the presence of aPL.
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16
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Coppola A, Lombardi M, Tassoni MI, Carolla G, Tala M, Morandini R, Paoletti O, Testa S. COVID-19, thromboembolic risk and thromboprophylaxis: learning lessons from the bedside, awaiting evidence. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:226-229. [PMID: 32453688 PMCID: PMC7250684 DOI: 10.2450/2020.0113-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Antonio Coppola
- Regional Reference Center for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Maria Lombardi
- Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Maria I. Tassoni
- Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Gaetano Carolla
- Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Maurizio Tala
- Haemostasis and Thrombosis Center, Cremona Hospital, Cremona, Italy
| | | | - Oriana Paoletti
- Haemostasis and Thrombosis Center, Cremona Hospital, Cremona, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Center, Cremona Hospital, Cremona, Italy
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17
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Antiphospholipid Antibody Testing in a General Population Sample from the USA: An Administrative Database Study. Sci Rep 2020; 10:3102. [PMID: 32080284 PMCID: PMC7033098 DOI: 10.1038/s41598-020-59990-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 01/27/2020] [Indexed: 12/02/2022] Open
Abstract
We sought to characterized patterns of aPL testing in a large general population sample from the United States. Using Truven Health MarketScan laboratory data from 2010–2015 we identified individuals tested for lupus anticoagulant(LA), anti-cardiolipin (aCL), and anti-beta2-glycoprotein1(aGP1). Our research was approved by the McGill institutional review board (A04-M47-12B). We identified 33,456 individuals with at least one aPL test. Among these, only 6,391 (19%) had all three tests (LA, aCL, aGP1) performed. Confirmatory aPL testing was performed at least 12 weeks later in 77%, 45%, and 41% of initially positive LA, aCL, and aGP1, respectively. Of those re-tested after ≥12 weeks, only 255 (10.6%) were found to have a confirmatory positive aPL test. These findings highlight that aPL testing may often be incompletely performed. Further investigations will be required to better understand the low rate of a confirmatory positive aPL test ≥12 weeks after the initial test.
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18
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Pignatelli P, Ettorre E, Menichelli D, Pani A, Violi F, Pastori D. Seronegative antiphospholipid syndrome: refining the value of "non-criteria" antibodies for diagnosis and clinical management. Haematologica 2020; 105:562-572. [PMID: 32001534 PMCID: PMC7049333 DOI: 10.3324/haematol.2019.221945] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 12/18/2019] [Indexed: 11/16/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombotic manifestations and/or pregnancy-related complications in patients with persistently high antiphospholipid antibodies (aPL), the most common being represented by anticardiolipin antibodies (aCL), anti-beta 2 glycoprotein-I (aβ2GPI), and lupus anticoagulant (LAC). A growing number of studies have showed that, in some cases, patients may present with clinical features of APS but with temporary positive or persistently negative titers of aPL. For these patients, the definition of seronegative APS (SN-APS) has been proposed. Nevertheless, the negativity to classic aPL criteria does not imply that other antibodies may be present or involved in the onset of thrombosis. The diagnosis of SN-APS is usually made by exclusion, but its recognition is important to adopt the most appropriate anti-thrombotic strategy to reduce the rate of recurrences. This research is in continuous development as the clinical relevance of these antibodies is far from being completely clarified. The most studied antibodies are those against phosphatidylethanolamine, phosphatidic acid, phosphatidylserine, phosphatidylinositol, vimentin/cardiolipin complex, and annexin A5. Moreover, the assays to measure the levels of these antibodies have not yet been standardized. In this review, we will summarize the evidence on the most studied non-criteria aPL, their potential clinical relevance, and the antithrombotic therapeutic strategies available in the setting of APS and SN-APS.
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Affiliation(s)
- Pasquale Pignatelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome.,Mediterranea Cardiocentro, Naples
| | - Evaristo Ettorre
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, Division of Gerontology, Sapienza University, Rome
| | - Danilo Menichelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome
| | - Arianna Pani
- Department of Oncology and Onco-Hematology, University of Milan, Milan.,Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome.,Mediterranea Cardiocentro, Naples
| | - Daniele Pastori
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome
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19
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Choi M, Butler E, Clarke A, Girard LP, Gibson P, Skeith L. Managing pregnancy-associated clinical emergencies in systemic lupus erythematosus: a case-based approach. Expert Rev Clin Immunol 2019; 16:5-22. [PMID: 31791152 DOI: 10.1080/1744666x.2019.1699057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE)-related thrombocytopenia during pregnancy and the postpartum period have been associated with adverse pregnancy outcomes and perinatal complications. In this case report, we present two SLE patients with thrombocytopenia emergencies secondary to HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome and thrombotic thrombocytopenic purpura (TTP).Areas covered: The first case involved a 26-year-old woman, G1P0 at 26 weeks gestation (GA), with high-titer antiphospholipid antibodies (aPL) (positive lupus anticoagulant, anti-beta 2 glycoprotein-1 (aβ2GP1), anti-cardiolipin) and non-criteria aPL to phosphatidylserine/prothrombin complex and anti-domain 1 β2GP1. This case highlights the risks associated with aPL in pregnancy, considers management issues relating to anticoagulation during pregnancy and highlights the importance of maintaining a high index of suspicion for diagnosis of HELLP in SLE patients. The second case was a 36-year-old female, G3P2 at 32 weeks GA, with class III lupus nephritis (LN) who developed severe pre-eclampsia, which included mild thrombocytopenia. This case illustrates the challenges in identifying and differentiating between three pregnancy emergencies that can be seen in SLE patients (pre-eclampsia, LN, and TTP) and presents the management of TTP in peripartum SLE.Expert opinion: These two cases remind us of the importance of timely diagnosis and management of thrombocytopenia in this population.
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Affiliation(s)
- May Choi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erin Butler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ann Clarke
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Louis Phillipe Girard
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Gibson
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Leslie Skeith
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Abstract
As a whole, rare stroke causes represent a frequent stroke etiology. Since rare stroke causes affect primarily young patients, early diagnosis and treatment are of high socioeconomic relevance. In our everyday clinical practice, cervical artery dissection, which is the most common stroke etiology among patients < 45 years, and vasculitis are particularly important. In the case of vasculitis, devastating disease courses and potentially harmful treatment options complicate clinical decision-making. Non-vasculitic vasculopathies, infections, hematological disorders, coagulation disorders, metabolic disorders and malignancies are further rare causes of stroke with variable clinical manifestations, thus impeding an early diagnosis. If eligible, patients with rare stroke causes should be considered for thrombectomy. Except for infective endocarditis, most rare stroke causes are not per se a contraindication to thrombolysis, so that eligible patients should also be considered for thrombolysis. Evidence based recommendations for the secondary prevention of most rare stroke causes are still missing. In many cases, treatment regimens are adapted to the patients' individual risk of stroke recurrence and bleeding complications.
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Zhang W, Zha C, Lu X, Jia R, Gao F, Sun Q, Jin M, Liu Y. Anti-β 2GPI/β 2GPI complexes induce platelet activation and promote thrombosis via p38MAPK: a pathway to targeted therapies. Front Med 2019; 13:680-689. [PMID: 30820805 DOI: 10.1007/s11684-018-0673-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 10/27/2018] [Indexed: 12/30/2022]
Abstract
Anti-β2 glycoprotein I (anti-β2GPI) antibodies are important contributors to the development of thrombosis. Anti-β2GPI antibody complexes with β2GPI are well known to activate monocytes and endothelial cells via the intracellular NF-kB pathway with prothrombotic implications. By contrast, the interaction of anti- β2GPI/β2GPI complexes with platelets has not been extensively studied. The p38 mitogen-activated protein kinase (MAPK) pathway has been recognized to be an important intracellular signaling pathway in the coagulation cascade and an integral component of arterial and venous thrombosis. The present study reveals that levels of anti- β2GPI/β2GPI complexes in sera are positively associated with p38MAPK phosphorylation of platelets in thrombotic patients. Furthermore, SB203580 inhibits anti-β2GPI/β2GPI complex-induced platelet activation. Thrombus formation decreased in p38MAPK-/- mice after treatment with anti-β2GPI/β2GPI complexes. In conclusion, p38MAPK may be a treatment target for anti-β2GPI antibody-associated thrombotic events.
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Affiliation(s)
- Wenjing Zhang
- Department of Laboratory Diagnosis, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Caijun Zha
- Department of Laboratory Diagnosis, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Xiumin Lu
- Department of Laboratory Diagnosis, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Ruichun Jia
- Department of Laboratory Diagnosis, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Fei Gao
- Department of Laboratory Diagnosis, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Qi Sun
- Department of Emergency, The First Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, 150040, China
| | - Meili Jin
- Department of Laboratory Diagnosis, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Yanhong Liu
- Department of Laboratory Diagnosis, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China.
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22
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Stachowicz A, Zabczyk M, Natorska J, Suski M, Olszanecki R, Korbut R, Wiśniewski JR, Undas A. Differences in plasma fibrin clot composition in patients with thrombotic antiphospholipid syndrome compared with venous thromboembolism. Sci Rep 2018; 8:17301. [PMID: 30470809 PMCID: PMC6251889 DOI: 10.1038/s41598-018-35034-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/26/2018] [Indexed: 12/13/2022] Open
Abstract
The prothrombotic fibrin clot phenotype has been reported in patients with thrombotic antiphospholipid syndrome (APS) and venous thromboembolism (VTE). Protein composition of plasma fibrin clots in APS has not been studied. We evaluated 23 patients with thrombotic APS, 19 with VTE alone, and 20 well-matched controls. A proteomic analysis of fibrin clots generated from citrated plasma was based on liquid chromatography-mass spectrometry. Plasma levels of thrombospondin-1 (TSP1), apolipoprotein(a), A-I, and B-100, complement components (C)3a, C5b-C9, histidine-rich glycoprotein (HRG), and prothrombin were evaluated using immunoenzymatic tests. In plasma fibrin clots of APS patients, compared with VTE subjects and controls, we identified decreased amounts of (pro)thrombin, antithrombin-III, apolipoprotein A-I, and HRG with no differences in plasma levels of antithrombin, prothrombin, along with lower plasma HRG and apolipoprotein A-I. In APS patients, plasma HRG positively correlated with amounts of clot-bound HRG, while apolipoprotein A-I was inversely associated with clot-bound levels of this protein. The most predominant proteins within the clots of APS patients were bone marrow proteoglycan, C5-C9, immunoglobulins, apolipoprotein B-100, platelet-derived proteins, and TSP1. Our study is the first to demonstrate differences in the protein composition of fibrin clots generated from plasma of thrombotic APS patients versus those with VTE alone.
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Affiliation(s)
- Aneta Stachowicz
- Chair of Pharmacology, Jagiellonian University Medical College, Krakow, Poland.,Biochemical Proteomics Group, Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Michal Zabczyk
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Joanna Natorska
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Krakow Center for Medical Research and Technology, John Paul II Hospital, Krakow, Poland
| | - Maciej Suski
- Chair of Pharmacology, Jagiellonian University Medical College, Krakow, Poland
| | - Rafał Olszanecki
- Chair of Pharmacology, Jagiellonian University Medical College, Krakow, Poland
| | - Ryszard Korbut
- Chair of Pharmacology, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek R Wiśniewski
- Biochemical Proteomics Group, Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland. .,Krakow Center for Medical Research and Technology, John Paul II Hospital, Krakow, Poland.
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Zuo Y, Barbhaiya M, Erkan D. Primary Thrombosis Prophylaxis in Persistently Antiphospholipid Antibody-Positive Individuals: Where Do We Stand in 2018? Curr Rheumatol Rep 2018; 20:66. [DOI: 10.1007/s11926-018-0775-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Bala MM, Paszek E, Lesniak W, Wloch‐Kopec D, Jasinska K, Undas A. Antiplatelet and anticoagulant agents for primary prevention of thrombosis in individuals with antiphospholipid antibodies. Cochrane Database Syst Rev 2018; 7:CD012534. [PMID: 30004572 PMCID: PMC6513409 DOI: 10.1002/14651858.cd012534.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is an autoimmune disease characterised by the presence of antiphospholipid (aPL) antibodies that have prothrombotic activity. Antiphospholipid antibodies are associated with an increased risk of pregnancy complications (recurrent miscarriage, premature birth, intrauterine growth retardation) and thrombotic events (both arterial and venous). The most common thrombotic events include brain ischaemia (stroke or transient ischaemic attack) and deep vein thrombosis. To diagnose APS, the presence of aPL antibodies in two measurements and at least one thrombotic event or pregnancy complication are required. It is unclear if people with positive aPL antibodies but without any previous thrombotic events should receive primary antithrombotic prophylaxis. OBJECTIVES To assess the effects of antiplatelet or anticoagulant agents versus placebo or no intervention or other intervention on the development of thrombosis in people with aPL antibodies who have not had a thrombotic event. We did not address obstetric outcomes in this review as these have been thoroughly addressed by other Cochrane Reviews. SEARCH METHODS We searched the Cochrane Vascular Specialised Register (4 December 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (last search 29 November 2017), MEDLINE Ovid, Embase Ovid, CINAHL, and AMED (searched 4 December 2017), and trials registries (searched 29 November 2017). We also checked reference lists of included studies, systematic reviews, and practice guidelines, and contacted experts in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any antiplatelet or anticoagulant agents, or their combinations, at any dose and mode of delivery with placebo, no intervention, or other intervention. We also included RCTs that compared antiplatelet or anticoagulant agents with each other or that compared two different doses of the same drug. We included studies performed in people of any age and with no history of thrombosis (as defined by APS Sapporo classification criteria or updated Sydney classification criteria), but with aPL antibodies confirmed on at last two separate measurements. The studies included both pregnant women who tested positive for aPL antibodies and had a history of recurrent obstetric complications, as well as non-pregnancy related cases with positive screening for antibodies, in accordance with the criteria mentioned above. DATA COLLECTION AND ANALYSIS Pairs of authors independently selected studies for inclusion, extracted data, and assessed the risk of bias for the included studies and quality of evidence using GRADE. Any discrepancies were resolved through discussion or by consulting a third review author when necessary. In addition, one review author checked all the extracted numerical data. MAIN RESULTS We included nine studies involving 1044 randomised participants. The studies took place in several countries and had different funding sources. No study was at low risk of bias in all domains. We classified all included studies as at unclear or high risk of bias in two or more domains. Seven included studies focused mainly on obstetric outcomes. One study included non-pregnancy-related cases, and one study included both pregnancy-related cases and other patients with positive results for aPL antibodies. The remaining studies concerned women with aPL antibodies and a history of pregnancy failure. Four studies compared anticoagulant with or without acetylsalicylic acid (ASA) versus ASA only and observed no clear difference in thrombosis risk (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.25 to 3.77; 4 studies; 493 participants; low-quality evidence). No major bleeding was reported, but minor bleeding risk (nasal bleeding, menorrhagia) was higher in the anticoagulant with ASA group as compared with ASA alone in one study (RR 22.45, 95% CI 1.34 to 374.81; 1 study; 164 participants; low-quality evidence). In one study ASA was compared with placebo, and there were no clear differences in thrombosis (RR 5.21, 95% CI 0.63 to 42.97; 1 study; 98 participants; low-quality evidence) or minor bleeding risk between the groups (RR 3.13, 95% CI 0.34 to 29.01; 1 study; 98 participants; low-quality evidence), and no major bleeding was observed. Two studies compared ASA with low molecular weight heparin (LMWH) versus placebo or intravenous immunoglobulin (IVIG), and no thrombotic events were observed in any of the groups. Moreover, there were no clear differences in the risk of bleeding requiring transfusion (RR 9.0, 95% CI 0.49 to 164.76; 1 study; 180 participants; moderate-quality evidence) or postpartum bleeding (RR 1.30, 95% CI 0.60 to 2.81; 1 study; 180 participants; moderate-quality evidence) between the groups. Two studies compared ASA with high-dose LMWH versus ASA with low-dose LMWF or unfractionated heparin (UFH); no thrombotic events or major bleeding was reported. Mortality and quality of life data were not reported for any of the comparisons. AUTHORS' CONCLUSIONS There is insufficient evidence to demonstrate benefit or harm of using anticoagulants with or without ASA versus ASA alone in people with aPL antibodies and a history of recurrent pregnancy loss and with no such history; ASA versus placebo in people with aPL antibodies; and ASA with LMWH versus placebo or IVIG, and ASA with high-dose LMWH versus ASA with low-dose LMWH or UFH, in women with aPL antibodies and a history of recurrent pregnancy loss, for the primary prevention of thrombotic events. In a mixed population of people with a history of previous pregnancy loss and without such a history treated with anticoagulant combined with ASA, the incidence of minor bleeding (nasal bleeding, menorrhagia) was increased when compared with ASA alone. Studies that are adequately powered and that focus mainly on thrombotic events are needed to draw any firm conclusions on the primary prevention of thrombotic events in people with antiphospholipid antibodies.
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Affiliation(s)
- Malgorzata M Bala
- Jagiellonian University Medical CollegeChair of Epidemiology and Preventive Medicine; Department of Hygiene and Dietetics; Systematic Reviews Unit ‐ Polish Cochrane BranchKopernika 7KrakowPoland31‐034
| | - Elżbieta Paszek
- Jagiellonian University Medical CollegeDepartment of Interventional CardiologyPradnicka 80KrakowPoland
| | - Wiktoria Lesniak
- Jagiellonian University Medical College2nd Department of Internal Medicineul. Skawinska 8KrakowPoland31‐066
| | - Dorota Wloch‐Kopec
- Jagiellonian University Medical CollegeNeurology DepartmentBotaniczna 3KrakowPoland31‐503
| | - Katarzyna Jasinska
- Jagiellonian University Medical CollegeStudents' Research Group, Systematic Reviews Unit‐Polish Cochrane BranchKrakowPoland
| | - Anetta Undas
- Jagiellonian University Medical CollegeInstitute of CardiologyPradnicka 80KrakowPoland31‐202
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Bala MM, Celinska‐Lowenhoff M, Szot W, Padjas A, Kaczmarczyk M, Swierz MJ, Undas A. Antiplatelet and anticoagulant agents for secondary prevention of stroke and other thromboembolic events in people with antiphospholipid syndrome. Cochrane Database Syst Rev 2017; 10:CD012169. [PMID: 28968483 PMCID: PMC6485894 DOI: 10.1002/14651858.cd012169.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial or venous thrombosis (or both) and/or pregnancy morbidity in association with the presence of antiphospholipid antibodies. The prevalence is estimated at 40 to 50 cases per 100,000 people. The most common sites of thrombosis are cerebral arteries and deep veins of the lower limbs. People with a definite APS diagnosis have an increased lifetime risk of recurrent thrombotic events. OBJECTIVES To assess the effects of antiplatelet or anticoagulant agents, or both, for the secondary prevention of recurrent thrombosis, particularly ischemic stroke, in people with antiphospholipid syndrome. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (February 2017), CENTRAL (last search February 2017), MEDLINE (from 1948 to February 2017), Embase (from 1980 to February 2017), and several ongoing trials registers. We also checked the reference lists of included studies, systematic reviews, and practice guidelines, and we contacted experts in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated any anticoagulant or antiplatelet agent, or both, in the secondary prevention of thrombosis in people diagnosed with APS according to the criteria valid when the study took place. We did not include studies specifically addressing women with obstetrical APS. DATA COLLECTION AND ANALYSIS Pairs of review authors independently selected studies for inclusion, extracted data, and assessed the risk of bias for the included studies. We resolved any discrepancies through discussion or by consulting a third review author and, in addition, one review author checked all the extracted data. MAIN RESULTS We included five studies involving 419 randomized participants with APS. Only one study was at low risk of bias in all domains. One study was at low risk of bias in all domains for objective outcomes but not for quality of life (measured using the EQ-5D-5L questionnaire). We judged the other three studies to be at unclear or high risk of bias in three or more domains.The duration of intervention ranged from 180 days to a mean of 3.9 years. One study compared rivaroxaban (a novel oral anticoagulant: NOAC) with standard warfarin treatment and reported no thrombotic or major bleeding events, but it was not powered to detect such differences (low-quality evidence). Investigators reported similar rates of clinically relevant non-major bleeding (risk ratio (RR) 1.45, 95% confidence interval (CI) 0.25 to 8.33; moderate-quality evidence) and minor bleeding (RR 1.21, 95% CI 0.51 to 2.83) for participants receiving rivaroxaban and the standard vitamin K antagonists (VKA). This study also reported some small benefit with rivaroxaban over the standard VKA treatment in terms of quality of life health state measured at 180 days with the EQ-5D-5L 100 mm visual analogue scale (mean difference (MD) 7 mm, 95% CI 2.01 to 11.99; low-quality evidence) but not measured as health utility (MD 0.04, 95% CI -0.02 to 0.10 [on a scale from 0 to 1]).Two studies compared high dose VKA (warfarin) with moderate/standard intensity VKA and found no differences in the rates of any thrombotic events (RR 2.22, 95% CI 0.79 to 6.23) or major bleeding (RR 0.74, 95% CI 0.24 to 2.25) between the groups (low-quality evidence). Minor bleeding analyzed using the RR and any bleeding using the hazard ratio (HR) were more frequent in participants receiving high-intensity warfarin treatment compared to the standard-intensity therapy (RR 2.55, 95% CI 1.07 to 6.07; and HR 2.03, 95% CI 1.12 to 3.68; low-quality evidence).In one study, it was not possible to estimate the RR for stroke with a combination of VKA plus antiplatelet agent compared to a single antiplatelet agent, while for major bleeding, a single event occurred in the single antiplatelet agent group. In one study, comparing combined VKA plus antiplatelet agent with dual antiplatelet therapy, the RR of the risk of stroke over three years of observation was 5.00 (95% CI 0.26 to 98.0). In a single small study, the RR for stroke during one year of observation with a dual antiplatelet therapy compared to single antiplatelet drug was 0.14 (95% CI 0.01 to 2.60). AUTHORS' CONCLUSIONS There is not enough evidence for or against NOACs or for high-intensity VKA compared to the standard VKA therapy in the secondary prevention of thrombosis in people with APS. There is some evidence of harm for high-intensity VKA regarding minor and any bleeding. The evidence was also not sufficient to show benefit or harm for VKA plus antiplatelet agent or dual antiplatelet therapy compared to a single antiplatelet drug. Future studies should be adequately powered, with proper adherence to treatment, in order to evaluate the effects of anticoagulants, antiplatelets, or both, for secondary thrombosis prevention in APS. We have identified five ongoing trials mainly using NOACs in APS, so increasing experimental efforts are likely to yield additional evidence of clinical relevance in the near future.
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Affiliation(s)
- Malgorzata M Bala
- Jagiellonian University Medical CollegeChair of Epidemiology and Preventive Medicine; Department of Hygiene and Dietetics; Systematic Reviews UnitKopernika 7KrakowPoland31‐034
| | - Magdalena Celinska‐Lowenhoff
- Jagiellonian University Medical College2nd Department of Internal Medicine, Department of Allergy and ImmunologySkawinska 8KrakowPoland31‐066
| | - Wojciech Szot
- Jagiellonian University Medical CollegeDepartment of Hygiene and DieteticsKrakowPoland
| | - Agnieszka Padjas
- Jagiellonian University Medical College2nd Department of Internal Medicine, Department of Allergy and ImmunologySkawinska 8KrakowPoland31‐066
| | - Mateusz Kaczmarczyk
- Jagiellonian University Medical CollegeSystematic Reviews Unit ‐ Polish Cochrane BranchKrakowPoland
| | - Mateusz J Swierz
- Jagiellonian University Medical CollegeDepartment of Hygiene and Dietetics, Systematic Reviews UnitKrakowPoland
| | - Anetta Undas
- Jagiellonian University Medical CollegeInstitute of CardiologyPradnicka 80KrakowPoland31‐202
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