Evidence-based management of thrombosis in the antiphospholipid antibody syndrome

Analysis of risk factors for the development of thrombotic complications in antiphospholipid antibody positive lupus patients

The objective of this study was to characterize risk factors for thrombotic events in lupus patients. A total of 272 lupus patients were followed up for five years during which the presence of aPL antibodies [anticardiolipin (aCL), anti-beta2-glycoprotein I (aβ2GPI) and lupus anticoagulant (LAC)] were determined, and all thrombotic incidents and antithrombotic therapy-related data were collected. At baseline, three groups were constituted, an aPL–group with 107 aPL negative patients, an aPL+ group with 81 aPL positive patients without clinical thrombosis and a secondary antiphospholipid syndrome (APS) group with 84 aPL+ patients who met the Sapporo criteria. LAC was more common in the APS than the aPL+ group (32.1% versus 9.9%, P < 0.001). The prevalence of clinical thrombotic events was significantly higher when all three types of aPL were present compared to only aCL positive cases. During follow up, aPL appeared in 7.5% of the aPL - group, and 2.8% of this group had thrombotic complications. In the aPL + group, thrombotic events reoccurred in 1.9% of those receiving antithrombotic prophylaxis and 6.9% of those without primary prophylaxis. Despite anticoagulant therapy, thrombotic events reoccurred in 8.3% of the APS group. These findings indicate that LAC, constant and cumulative presence of aPL and previous thrombosis are positive predictors for the development of thrombotic complication in lupus patients.

Review on Effectiveness of Primary Prophylaxis in aPLs with and without Risk Factors for Thrombosis: Efficacy and Safety

Context. Antiphospholipid antibodies syndrome is an autoimmune disorder that is characterized by the association between presence of antiphospholipid antibodies and risk of thrombosis and/or pregnancy morbidity. Objectives. To systematically review the evidence for primary prophylaxis in patients with antiphospholipids antibodies syndrome or APS with or without other traditional risk factors of thrombosis when they did not have any thrombotic event yet. Methods. PubMed, the Cochrane Library, and Allied Health Literature were searched for studies that examined the efficacy and safety of primary prophylaxis in aPL patients from 1990 to February 2013. We examined literature looking at patients with aPLs with other risk factors for thrombosis and aPLs with no additional risk factors for thrombosis. Conclusion. We concluded that, in patients with aPLs, primary prophylaxes with HCQ and aspirin have been observed to reduce the frequency of thrombotic events in the case of asymptomatic aPL-positive patients with SLE. We also in this study concluded that LDA was effective in patients with autoimmune diseases. Independent cardiovascular risk factors include autoimmune defects such as SLE, rheumatoid arthritis, and atherosclerosis, where overall venous thrombosis will be induced by systemic inflammation. This review concludes that HCQ is an effective primary approach when compared to aspirin.

Treatment of the antiphospholipid antibody syndrome

Numerous questions exist regarding the proper management of patients with the antiphospholipid antibody syndrome (APS). Several recent, randomized-controlled trials have been conducted that attempt to answer the fundamental questions of whom to treat, how to treat, and for how long treatment should last. These studies suggest that APS should be categorized by disease manifestations, and these presentations may have different treatment algorithms. A better understanding of the immune mechanisms that govern thrombosis in this syndrome has led to a wide array of innovative treatment approaches that will require meticulous study.

Antiphospholipid antibodies: update on detection, pathophysiology, and treatment

PURPOSE OF REVIEW

The antiphospholipid syndrome is a noninflammatory disease characterized by the presence of antiphospholipid antibodies in the plasma of patients with venous or arterial thrombosis or obstetric complications. Understanding of the pathology of the syndrome is only rudimentary and no physician can pretend that treatment is adequate. It is not possible to identify patients with the syndrome for certain. This paper reviews the substantial and promising headway made in the past year.

RECENT FINDINGS

It has become clear that lupus anticoagulant is the assay of choice to detect the syndrome and that antibodies directed towards beta2Glycoprotein 1 are the clinical relevant autoantibodies. These antibodies are able to activate a number of cells involved in the regulation of hemostasis.

SUMMARY

The latest developments will make it soon possible to define patient with the syndrome unambiguously. This is absolutely necessary to understand why the presence of antiphospholipid antibodies cause an increased thrombotic risk.

Complement system on the attack in autoimmunity

The antiphospholipid syndrome is characterized clinically by fetal loss and thrombosis and serologically by the presence of autoantibodies to lipid-binding proteins. In a model of this procoagulant condition in which these antibodies are injected into pregnant mice, fetal loss was prevented by blocking of complement activation. Specifically, interaction of complement component 5a (C5a) with its receptor is necessary for thrombosis of placental vasculature. Inhibition of complement activation may have a therapeutic role in this disease.