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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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Brady CA, Ford LB, Moss C, Zou Z, Crocker IP, Heazell AEP. Virtual crossmatching reveals upregulation of placental HLA-Class II in chronic histiocytic intervillositis. Sci Rep 2024; 14:18714. [PMID: 39134702 PMCID: PMC11319473 DOI: 10.1038/s41598-024-69315-5] [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: 06/09/2023] [Accepted: 08/02/2024] [Indexed: 08/15/2024] Open
Abstract
Chronic histiocytic intervillositis (CHI) is a recurrent placental lesion where maternal macrophages infiltrate the intervillous space. Its cause is unknown, though due to similarities to rejected allografts one hypothesis is that CHI represents maternal-fetal rejection. Here, virtual crossmatching was applied to healthy pregnancies and those with a history of CHI. Anti-HLA antibodies, measured by Luminex, were present in slightly more controls than CHI (8/17 (47.1%) vs 5/14 (35.7%)), but there was no significant difference in levels of sensitisation or fetal specific antibodies. Quantification of immunohistochemical staining for HLA-Class II was increased in syncytiotrophoblast of placentas with CHI (Grade 0.44 [IQR 0.1-0.7]) compared to healthy controls (0.06 [IQR 0-0.2]) and subsequent pregnancies (0.13 [IQR 0-0.3]) (P = 0.0004). HLA-Class II expression was positively related both to the severity of CHI (r = 0.67) and C4d deposition (r = 0.48). There was no difference in overall C4d and HLA-Class I immunostaining. Though increased anti-HLA antibodies were not evident in CHI, increased expression of HLA-Class II at the maternal-fetal interface suggests that they may be relevant in its pathogenesis. Further investigation of antibodies immediately after diagnosis is warranted in a larger cohort of CHI cases to better understand the role of HLA in its pathophysiology.
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Affiliation(s)
- Chloe A Brady
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK.
| | - Laura B Ford
- Transplantation Laboratory, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Chloe Moss
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK
| | - Zhiyong Zou
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK
| | - Ian P Crocker
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK
| | - Alexander E P Heazell
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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3
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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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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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Wahl D, Pengo V. Viewpoint: Provoked thrombosis in antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI37-SI45. [PMID: 38320585 DOI: 10.1093/rheumatology/kead675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/05/2023] [Indexed: 02/08/2024] Open
Abstract
Unprovoked thrombosis (thrombosis occurring without an established environmental factor favouring the episode) is a classic feature of APS. In the general population, provoked venous thromboembolism (VTE) is clearly defined and has clinical and therapeutic differences compared with unprovoked VTE. Whether provoked VTE in the context of APS may lead to a limited treatment duration is not well established. Therefore, careful clinical and laboratory evaluation is needed to identify patients eligible for a limited duration of anticoagulation treatment after provoked VTE. Given the uncertainties of available data, the risks and benefits of treatment decisions should be clearly explained. Decisions should be shared by both the patient and physician. Cardiovascular risk factors are common in patients with APS with arterial thrombosis. There are insufficient data suggesting that cardiovascular risk factor control would allow the cessation of anticoagulation. In most instances, arterial thrombosis will require prolonged anticoagulants. A careful analysis of clinical characteristics and laboratory evaluation, particularly the aPL antibody profile, is needed to make decisions on a case-by-case basis.
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Affiliation(s)
- Denis Wahl
- Université de Lorraine, CHRU-Nancy, Vascular Medicine and Rare Vascular Diseases Division, and National Referral Center for Systemic Autoimmune Diseases, Inserm, UMR 1116 DCAC, Nancy, France
| | - Vittorio Pengo
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padua, Padua, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
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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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7
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Fierro JJ, Velásquez-Berrío M, Ospina A, Henning S, de Leeuw K, Cadavid J ÁP. The effects of hydroxychloroquine and its promising use in refractory obstetric antiphospholipid syndrome. Rheumatol Int 2024; 44:223-234. [PMID: 37741812 PMCID: PMC10796698 DOI: 10.1007/s00296-023-05457-5] [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: 08/11/2023] [Accepted: 09/01/2023] [Indexed: 09/25/2023]
Abstract
Hydroxychloroquine (HCQ) is obtained by hydroxylation of chloroquine (CQ) and the first indication was malaria. Nowadays, HCQ is commonly used in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) with favorable results. Antiphospholipid syndrome (APS) is an autoimmune disease characterized by thrombosis and/or pregnancy morbidity and persistent positivity of antiphospholipid antibodies. Around 20-30% of pregnant women with APS develop adverse pregnancy outcomes despite conventional treatment with aspirin and heparin, called refractory obstetric APS. Interestingly, HCQ has shown positive effects on top of the standard of care in some refractory obstetric APS patients. HCQ mechanisms of action in APS comprise its ability to bind sialic acid present in cell membranes, its capacity to block the binding of antiphospholipid antibodies to the cell and the induced increase of pH in extracellular and intracellular compartments. However, the precise mechanisms of HCQ in the specific situation of refractory APS still need to be fully clarified. Therefore, this review summarizes the known modulating effects of HCQ and CQ, their side effects and use in APS and different pathologies to understand the benefit effects and the mechanism of action of HCQ in refractory obstetric APS.
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Affiliation(s)
- Juan J Fierro
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands.
- Grupo Reproducción, Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia.
| | - Manuela Velásquez-Berrío
- Grupo Reproducción, Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Alexandra Ospina
- Grupo Reproducción, Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Svenja Henning
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
| | - Karina de Leeuw
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
| | - Ángela P Cadavid J
- Grupo Reproducción, Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
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8
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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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Garg S, Chewning B, Hutson P, Astor BC, Bartels CM. Reference Range of Hydroxychloroquine Blood Levels That Can Reduce Odds of Active Lupus and Prevent Flares. Arthritis Care Res (Hoboken) 2024; 76:241-250. [PMID: 37667434 DOI: 10.1002/acr.25228] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/04/2023] [Accepted: 08/31/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Recent data show that lower hydroxychloroquine (HCQ) doses are associated with a two- to six-fold higher risk of lupus flares. Thus, establishing an effective reference range of HCQ blood levels with upper and lower bounds for efficacy may support individualizing HCQ dosing to prevent flares. METHODS HCQ levels in whole blood and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) were measured during the baseline visit and again during a standard of care routine follow-up visit. Active cross-sectional lupus at baseline was defined as SLEDAI ≥6; a within subject flare was defined as a subsequent three-point increase in SLEDAI with clinical symptoms requiring therapy change. We examined associations between active lupus and HCQ blood levels at baseline and flares and HCQ levels during 6 to 12-month routine lupus follow-up visits using mixed regression analysis. RESULTS Among 158 baseline patient visits, 19% had active lupus. Odds of active lupus were 71% lower in patients with levels within a 750 to 1,200 ng/mL range (adjusted odds ratio 0.29, 95% confidence interval 0.08-0.96). Using convenience sampling strategy during a pandemic, we longitudinally followed 42 patients. Among those patients, 17% flared during their follow-up visit. Maintaining HCQ levels within 750 to 1,200 ng/mL reduced the odds of a flare by 26% over a nine-month median follow-up. CONCLUSION An effective reference range of HCQ blood levels, 750 to 1,200 ng/mL, was associated with 71% lower odds of active lupus, and maintaining levels within this range reduced odds of flares by 26%. These findings could guide clinicians to individualize HCQ doses to maintain HCQ levels within this range to maximize efficacy.
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Affiliation(s)
- Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Paul Hutson
- University of Wisconsin School of Pharmacy, Madison
| | - Brad C Astor
- University of Wisconsin School of Medicine and Public Health, Madison
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Fan Y, Xu Y, Zhang S, Song X, Liu Z, Tu W, Li C. Stroke and Risk Factors in Antiphospholipid Syndrome. J Pers Med 2023; 14:24. [PMID: 38248725 PMCID: PMC10821242 DOI: 10.3390/jpm14010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Stroke is considered one of the most common and life-threatening manifestations of antiphospholipid syndrome (APS), which leads to high mortality and permanent disability. This study investigated the prevalence and the potential risk factors of stroke in APS. We enrolled 361 APS patients retrospectively from 2009 to 2022 at Peking University People's Hospital. Stroke was found in 25.8% (93/361) of the participants. The multivariate logistic regression showed that hypertension, diabetes, livedo reticularis, and other central nervous system involvements were significant related factors for stroke. The use of hydroxychloroquine appeared to relate to a lower incidence of stroke. During a median follow-up of 3.0 years, 11.8% (11/93) of the individuals with a previous stroke developed stroke recurrence, and thrombocytopenia seemed to be a predictor of stroke recurrence.
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Affiliation(s)
- Yangyi Fan
- Department of Neurology, Peking University People’s Hospital, Beijing 100044, China; (Y.F.); (X.S.); (Z.L.)
| | - Yicheng Xu
- Department of Neurology, Aerospace Center Hospital, Beijing 100049, China
| | - Sifan Zhang
- Peking University People’s Hospital, Beijing 100191, China;
| | - Xiaodong Song
- Department of Neurology, Peking University People’s Hospital, Beijing 100044, China; (Y.F.); (X.S.); (Z.L.)
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400042, China
| | - Zunjing Liu
- Department of Neurology, Peking University People’s Hospital, Beijing 100044, China; (Y.F.); (X.S.); (Z.L.)
| | - Wenjun Tu
- Department of Neurosurgery, Tiantan Hospital, Beijing 100050, China
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing 100044, China
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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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Pengo V, Denas G. Antiphospholipid Syndrome in Patients with Venous Thromboembolism. Semin Thromb Hemost 2023; 49:833-839. [PMID: 35728601 DOI: 10.1055/s-0042-1749590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Unprovoked (or provoked by mild risk factors) venous thromboembolism (VTE) in young patients, VTE in uncommon sites, or cases of unexplained VTE recurrence may be positive for antiphospholipid antibodies (aPL) and thus may be diagnosed with antiphospholipid syndrome (APS). The evaluation of aPL is standardized using immunological tests for anticardiolipin and anti-β2-glycoprotein I. The determination of functional antibodies (lupus anticoagulant) is less standardized, especially in patients on anticoagulant treatment. Patients positive for all the three tests are at high risk of recurrence, which, in turn, might lead to chronic obstruction of pulmonary vessels (chronic thromboembolic pulmonary hypertension). Randomized clinical trials have shown that triple-positive patients should be treated with vitamin K antagonists maintaining an international normalized ratio between 2 and 3. Whether patients with VTE and incomplete aPL profile can be treated with direct oral anticoagulants should be further investigated.
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Affiliation(s)
- Vittorio Pengo
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Gentian Denas
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padova, Padova, Italy
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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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Kowatsch MM, Lajoie J, Mwangi L, Omollo K, Oyugi J, Hollett N, Kimani J, Fowke KR. Hydroxychloroquine reduces T cells activation recall antigen responses. PLoS One 2023; 18:e0287738. [PMID: 37531383 PMCID: PMC10395872 DOI: 10.1371/journal.pone.0287738] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 06/04/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND In the context of the current COVID-19 pandemic, there is still limited information about how people suffering from autoimmune diseases respond to the different COVID vaccines. The fact that they are taking an immunosuppressant or other drugs that aim to decrease the immune system activities, such as hydroxychloroquine (HCQ), could also impact their ability to respond to a COVID vaccine and vaccines in general. METHODS Heathy donors were given 200mg of HCQ daily for 6-weeks to assess HCQs impact on the systemic T cells and humoral immune response. Peripheral blood mononuclear cells (PBMC) and plasma were obtained at baseline and 6-weeks after starting daily HCQ. Flow cytometry assays were designed to determine changes in T cell activation and T cell responses. Bead array multiplex were used to analyse antibodies and cytokine levels before and after HCQ intake. RESULTS As anticipated, HCQ treatment decreased ex vivo T cell activation. We observed a decrease in CD4+CD161- expressing CCR5 (p = 0.015) and CD69 (p = 0.004) as well as in CD8+CCR5+ (p = 0.003), CD8+CD161+CCR5+ (p = 0.002) and CD8+CD161+CD95+ (p = 0.004). Additionally, HCQ decreased the proportion of Th17 expressing CD29 (p = 0.019), a subset associated with persistent inflammation. The proportion of T regulatory cells expressing the inhibitory molecule TIGIT was also reduced by HCQ (p = 0.003). As well, T cells from people on HCQ were less responsive to activation and cytokine production following stimulation with recall antigens and memory T cells were less likely to produce both IFNγ and TNFα following stimulation. CONCLUSION This study shows HCQ is associated with lower T cell activation and decreased T cell cytokine production. While this study was not performed with the intent of looking at COVID vaccine response, it does provide important information about the changes in immune response that may occur in patient taking HCQ as a treatment for their autoimmune disease.
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Affiliation(s)
- Monika M Kowatsch
- Laboratory of Viral Immunology, Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Lajoie
- Laboratory of Viral Immunology, Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Lucy Mwangi
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Kenneth Omollo
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Julius Oyugi
- Laboratory of Viral Immunology, Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- Partners for Health and Development in Africa, Nairobi, Kenya
- University of Nairobi Institute for Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Natasha Hollett
- Laboratory of Viral Immunology, Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Kimani
- Laboratory of Viral Immunology, Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- Partners for Health and Development in Africa, Nairobi, Kenya
- University of Nairobi Institute for Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Keith R Fowke
- Laboratory of Viral Immunology, Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Partners for Health and Development in Africa, Nairobi, Kenya
- Department of Community Health Science, University of Manitoba, Winnipeg, Manitoba, Canada
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Sakowicz A, Bralewska M, Rybak-Krzyszkowska M, Grzesiak M, Pietrucha T. New Ideas for the Prevention and Treatment of Preeclampsia and Their Molecular Inspirations. Int J Mol Sci 2023; 24:12100. [PMID: 37569476 PMCID: PMC10418829 DOI: 10.3390/ijms241512100] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Preeclampsia (PE) is a pregnancy-specific disorder affecting 4-10% of all expectant women. It greatly increases the risk of maternal and foetal death. Although the main symptoms generally appear after week 20 of gestation, scientific studies indicate that the mechanism underpinning PE is initiated at the beginning of gestation. It is known that the pathomechanism of preeclampsia is strongly related to inflammation and oxidative stress, which influence placentation and provoke endothelial dysfunction in the mother. However, as of yet, no "key players" regulating all these processes have been discovered. This might be why current therapeutic strategies intended for prevention or treatment are not fully effective, and the only effective method to stop the disease is the premature induction of delivery, mostly by caesarean section. Therefore, there is a need for further research into new pharmacological strategies for the treatment and prevention of preeclampsia. This review presents new preventive methods and therapies for PE not yet recommended by obstetrical and gynaecological societies. As many of these therapies are in preclinical studies or under evaluation in clinical trials, this paper reports the molecular targets of the tested agents or methods.
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Affiliation(s)
- Agata Sakowicz
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
| | - Michalina Bralewska
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
| | - Magda Rybak-Krzyszkowska
- Department of Obstetrics and Perinatology, University Hospital in Krakow, 31-501 Krakow, Poland;
| | - Mariusz Grzesiak
- Department of Perinatology, Obstetrics and Gynecology, Polish Mother’s Memorial Hospital-Research Institute in Lodz, 93-338 Lodz, Poland;
- Department of Gynecology and Obstetrics, Medical University of Lodz, 93-338 Lodz, Poland
| | - Tadeusz Pietrucha
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
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Garg S, Ferguson S, Chewning B, Gomez S, Keevil J, Bartels C. Clarifying misbeliefs about hydroxychloroquine (HCQ): developing the HCQ benefits versus harm decision aid (HCQ-SAFE) per low health literacy standards. Lupus Sci Med 2023; 10:e000935. [PMID: 37500292 PMCID: PMC10387621 DOI: 10.1136/lupus-2023-000935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Up to 83% of patients with SLE stop taking hydroxychloroquine (HCQ) within the first year due to knowledge gaps regarding the survival benefits of HCQ versus inflated fears of rare toxicity. Thus, there is a need for a shared decision-making tool that highlights HCQ's significant benefits versus rare harms to improve patients' understanding and align treatments with their values. The objective of this study was to describe development and piloting of a decision aid (HCQ-SAFE) to facilitate HCQ adherence, and safe, effective use by engaging patients in therapeutic decision-making. METHODS HCQ-SAFE was developed via a collaborative process involving patients, clinicians, implementation scientists and health literacy experts. The initial prototype was informed by Agency for Healthcare Research and Quality (AHRQ) low literacy principles and key themes about HCQ use from six prior patient and clinician focus groups, with iterative expert and stakeholder feedback to deliver a final prototype. We implemented HCQ-SAFE in four clinics to examine usability and feasibility on Likert scales (0-7) and net promoter score (0%-100%). RESULTS The final HCQ-SAFE shared decision-making laminated tool organises data using pictograms showing how HCQ use reduces risk of organ damage, early death and blood clots versus low risk of eye toxicity.HCQ-SAFE was reviewed in all eligible patient visits (n=40) across four clinics on an average of ~8 min, including 25% non-English-speaking patients. All patients scored 100% on the knowledge post-test; no decisional conflicts were noted after using HCQ-SAFE. HCQ-SAFE garnered high clinician and patient satisfaction with 100% likelihood to recommend to peers. CONCLUSIONS HCQ-SAFE is a stakeholder-informed feasible shared decision-making tool that enhances communication and can potentially improve knowledge, clarify misbeliefs and engage patients in treatment decisions, including those with limited English proficiency.
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Affiliation(s)
- Shivani Garg
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sancia Ferguson
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Betty Chewning
- Department of Pharmacy, School of Pharmacy, Madison, Wisconsin, USA
| | - Shelby Gomez
- Department of Pharmacy, School of Pharmacy, Madison, Wisconsin, USA
| | | | - Christie Bartels
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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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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Urrego-Callejas T, Hernández A, Ruiz Giraldo S, Frade-Sosa B, Vanegas-García AL, Muñoz CH, Rua C, Duque Botero J, González LA, Vásquez G, Gómez-Puerta JA. Relevance of non-criteria antiphospholipid antibodies titers among patients with antiphospholipid syndrome and patients with systemic lupus erythematosus. REUMATOLOGIA CLINICA 2023; 19:197-203. [PMID: 37061281 DOI: 10.1016/j.reumae.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 07/07/2022] [Indexed: 04/17/2023]
Abstract
BACKGROUND There is an increasing interest in the study of non-criteria antiphospholipid antibodies (aPL) including antibodies targeting domain 1 of the B2 glycoprotein 1 (anti-D1 B2GP1) and antibodies anti phosphatidylserine/ prothrombin (PS/PT). OBJECTIVES Our aim was to analyze a panel of conventional and non-criteria aPL in a cohort of patients with systemic lupus erythematosus (SLE) and primary antiphospholipid syndrome (APS), to describe if there are differences in aPL titers among groups, to evaluate clinical associations including risk of recurrent events of novel aPL. METHODS Observational study that evaluated at baseline antibodies against anti-D1 B2GP1 and anti PS/PT. Anti-D1 B2GP1 antibodies were tested using a chemiluminescent immunoassay. IgG and IgM anti PS/PT, aCL and anti B2GP1 by ELISA techniques. Therefore, patients were followed in order to identify new thrombotic events. RESULTS 133 patients with SLE and 23 with primary APS patients were included. Main APS manifestations were DVT (27%), obstetric morbidity (22%) and arterial thrombosis (10.1%). IgM anti PS/PT antibodies levels were (20.6 - 127) vs 21.9 (11.2 - 39.2) U/ml, p<0.001 in primary APS vs SLE with APS, respectively. Anti-D1 B2GP1, IgG and IgM anti PS/PT were associated with thrombotic and non-thrombotic manifestations. During follow-up, IgG B2GP1 were related with a significant cumulative risk of thrombosis. CONCLUSIONS We found significant differences in serum titers of non-criteria aPL among patients with primary APS vs SLE with APS. Whether non-criteria aPL antibodies titers are useful to differentiate patients with primary and secondary APS requires further analysis in other populations.
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Affiliation(s)
- Tomás Urrego-Callejas
- Grupo de Inmunología Celular e Inmunogenética, Universidad de Antioquia, Medellín, Colombia
| | - Alejandro Hernández
- Departamento de Medicina Interna, Universidad de Antioquia, Medellín, Colombia
| | | | | | - Adriana L Vanegas-García
- Grupo de Reumatología, Universidad de Antioquia y Hospital San Vicente Fundación, Medellín, Colombia
| | - Carlos H Muñoz
- Grupo de Reumatología, Universidad de Antioquia y Hospital San Vicente Fundación, Medellín, Colombia
| | - Carolina Rua
- Grupo de Investigación en Trombosis, Universidad de Antioquia, Medellín, Colombia
| | | | - Luis A González
- Grupo de Reumatología, Universidad de Antioquia y Hospital San Vicente Fundación, Medellín, Colombia
| | - Gloria Vásquez
- Grupo de Inmunología Celular e Inmunogenética, Universidad de Antioquia, Medellín, Colombia; Departamento de Medicina Interna, Universidad de Antioquia, Medellín, Colombia
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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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21
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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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23
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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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24
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Abstract
The diagnosis of antiphospholipid syndrome (APS) relies on the detection of circulating antiphospholipid antibodies (aPL). Currently, lupus anticoagulant (LA), anticardiolipin (aCL), and anti-β2-glycoprotein I antibodies (aβ2GPI) IgG or IgM are the laboratory criteria if persistently present over time. As aCL and aβ2GPI are two out of the three laboratory criteria, the detection of aPL by solid phase assays is an essential step in the diagnosis of APS. Advancement has been made to resolve some of the methodological challenges of aCL and aβ2GPI assays by providing guidelines how to measure aPL, as well as to gain a better understanding of their diagnostic role. However, solid phase assays for aCL and aβ2GPI still show substantive inter-assay differences, resulting in disagreement concerning positive/negative results, but also differences in titer of antibodies. This hampers the semiquantitative classification into low-medium-high positivity. The non-criteria aPL, such as antibodies against the domain one of β2GPI and anti-phosphatidylserine/prothrombin antibodies (aPS/PT) have roles in confirming the risk in APS, and can be useful, especially in patients with incomplete antibody profiles.
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Affiliation(s)
- Katrien M J Devreese
- Department of Diagnostic Sciences, Coagulation Laboratory, Ghent University Hospital, Ghent University, Ghent, Belgium
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25
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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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26
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Madison JA, Gockman K, Hoy C, Tambralli A, Zuo Y, Knight JS. Pediatric antiphospholipid syndrome: clinical features and therapeutic interventions in a single center retrospective case series. Pediatr Rheumatol Online J 2022; 20:17. [PMID: 35197077 PMCID: PMC8867616 DOI: 10.1186/s12969-022-00677-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/PURPOSE Pediatric antiphospholipid syndrome (APS) is a thromboinflammatory disease characterized by the presence of circulating antiphospholipid antibodies and either thrombotic events or pregnancy morbidity. The objective of this study was to review a large institution's experience to better understand the characteristics of children with APS. METHODS We conducted a retrospective review of pediatric APS at a tertiary referral center. The electronic medical record system was queried from 2000 through 2019, and 21 cases were included based on meeting the revised Sapporo Classification criteria by age 18 or younger. Comparisons between primary and secondary APS patients were made with two-tailed t-tests. RESULTS Twenty-one patients were included with a median age at diagnosis of 16 years and median follow-up of 5.8 years. Secondary APS was slightly more common than primary APS (11 vs. 10 cases) and was primarily diagnosed in the context of systemic lupus erythematosus. Two thirds of patients (67%) also had "non-criteria" manifestations of APS including thrombocytopenia, autoimmune hemolytic anemia, and livedo reticularis/racemosa. Almost half of patients (43%) had recurrent thrombosis, typically when patients were subtherapeutic or non-adherent with anticoagulation. Damage Index in Patients with Thrombotic APS (DIAPS) scores indicated a chronic burden of disease in both primary and secondary APS patients. CONCLUSION This case series of pediatric APS provides important context regarding disease phenotypes displayed by children with APS. High prevalence of non-criteria clinical manifestations highlights the need to consider these characteristics when developing pediatric-specific classification criteria and when considering this relatively rare diagnosis in pediatric practice.
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Affiliation(s)
- Jacqueline A. Madison
- grid.214458.e0000000086837370Department of Pediatrics, Division of Pediatric Rheumatology, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Kelsey Gockman
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Claire Hoy
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Ajay Tambralli
- grid.214458.e0000000086837370Department of Pediatrics, Division of Pediatric Rheumatology, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Yu Zuo
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Jason S. Knight
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
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27
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Sevim E, Zisa D, Andrade D, Sciascia S, Pengo V, Tektonidou MG, Ugarte A, Gerosa M, Michael Belmont H, Zamorano MAA, Fortin PR, Ji L, Efthymiou M, Cohen H, Ware Branch D, de Jesus GR, Andreoli L, Petri M, Rodriguez E, Cervera R, Knight JS, Atsumi T, Willis R, Roubey R, Bertolaccini ML, Erkan D, Barbhaiya M. Characteristics of Patients With Antiphospholipid Antibody Positivity in the APS ACTION International Clinical Database and Repository. Arthritis Care Res (Hoboken) 2022; 74:324-335. [PMID: 32986935 PMCID: PMC10725727 DOI: 10.1002/acr.24468] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 09/04/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2023]
Abstract
OBJECTIVE To describe the baseline characteristics of patients with positivity for antiphospholipid antibodies (aPLs) who were enrolled in an international registry, the Antiphospholipid Syndrome (APS) Alliance for Clinical Trials and International Networking (APS ACTION) clinical database and repository, overall and by clinical and laboratory subtypes. METHODS The APS ACTION registry includes adults who persistently had positivity for aPLs. We evaluated baseline sociodemographic and aPL-related (APS classification criteria and "non-criteria") characteristics of patients overall and in subgroups (aPL-positive without APS, APS overall, thrombotic APS only, obstetric APS only, and both thrombotic APS/obstetric APS). We assessed baseline characteristics of patients tested for the presence of three aPLs (lupus anticoagulant [LAC] test, anticardiolipin antibody [aCL], and anti-β2 -glycoprotein I [anti-β2 GPI]) antibodies by aPL profiles (LAC only, single, double, and triple aPL positivity). RESULTS The 804 aPL-positive patients assessed in the present study had a mean age of 45 ± 13 years, were 74% female, and 68% White; additionally, 36% had other systemic autoimmune diseases. Of these 804 aPL-positive patients, 80% were classified as having APS (with 55% having thrombotic APS, 9% obstetric APS, and 15% thrombotic APS/obstetric APS). In the overall cohort, 71% had vascular thrombosis, 50% with a history of pregnancy had obstetric morbidity, and 56% had experienced at least one non-criteria manifestation. Among those with three aPLs tested (n = 660), 42% were triple aPL-positive. While single-, double-, and triple aPL-positive subgroups had similar frequencies of vascular, obstetric, and non-criteria events, these events were lowest in the single aPL subgroup, which consisted of aCLs or anti-β2 GPI only. CONCLUSION Our study demonstrates the heterogeneity of aPL-related clinical manifestations and laboratory profiles in a multicenter international cohort. Within single aPL positivity, LAC may be a major contributor to clinical events. Future prospective analyses, using standardized core laboratory aPL tests, will help clarify aPL risk profiles and improve risk stratification.
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Affiliation(s)
- Ecem Sevim
- Ecem Sevim, MD: Hospital for Special Surgery, New York, New York, and Montefiore Medical Center, Bronx, New York
| | - Diane Zisa
- Diane Zisa, MD, Doruk Erkan, MD, MPH, Medha Barbhaiya, MD, MPH: Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Danieli Andrade
- Danieli Andrade, MD, PhD: University of Sao Paulo, Sao Paulo, Brazil
| | | | - Vittorio Pengo
- Vittorio Pengo, MD: University Hospital Padova, Padova, Italy
| | - Maria G. Tektonidou
- Maria G. Tektonidou, MD: National and Kapodistrian University of Athens, Athens, Greece
| | - Amaia Ugarte
- Amaia Ugarte, MD: Hospital Universitario Cruces, Barakaldo, País Vasco, Spain
| | - Maria Gerosa
- Maria Gerosa, MD, PhD: University of Milan, Milan, Italy
| | - H. Michael Belmont
- H. Michael Belmont, MD: New York University Langone Medical Center, New York, New York
| | | | - Paul R. Fortin
- PaulR. Fortin, MD, PhD: CHU de Québec and Université Laval, Quebec City, Canada
| | - Lanlan Ji
- Lanlan Ji, MD: Peking University First Hospital, Beijing, China
| | - Maria Efthymiou
- MariaEfthymiou, PhD, Hannah Cohen, MD: University College London, London, UK
| | - Hannah Cohen
- MariaEfthymiou, PhD, Hannah Cohen, MD: University College London, London, UK
| | - D. Ware Branch
- D. Ware Branch, MD: University of Utah and Intermountain Healthcare, Salt Lake City, Utah
| | | | - Laura Andreoli
- Laura Andreoli, MD, PhD: University of Brescia, Brescia, Italy
| | - Michelle Petri
- Michelle Petri, MD, MPH: Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Esther Rodriguez
- Esther Rodriguez, MD: Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ricard Cervera
- Ricard Cervera, MD, PhD, FRCP: Hospital Clínic Institut d’Investigacions Biomèdiques August Pi i Sunyer(IDIBAPS), Barcelona, Catalonia, Spain
| | | | - Tatsuya Atsumi
- Tatsuya Atsumi, MD, PhD: Hokkaido University Hospital, Sapporo, Japan
| | - Rohan Willis
- Rohan Willis, MD: University of Texas Medical Branch, Galveston
| | - Robert Roubey
- Robert Roubey, MD: University of North Carolina, Chapel Hill
| | | | - Doruk Erkan
- Diane Zisa, MD, Doruk Erkan, MD, MPH, Medha Barbhaiya, MD, MPH: Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Medha Barbhaiya
- Diane Zisa, MD, Doruk Erkan, MD, MPH, Medha Barbhaiya, MD, MPH: Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
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28
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Meroni PL, Borghi MO. Antiphospholipid Antibody Assays in 2021: Looking for a Predictive Value in Addition to a Diagnostic One. Front Immunol 2021; 12:726820. [PMID: 34621272 PMCID: PMC8490700 DOI: 10.3389/fimmu.2021.726820] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022] Open
Abstract
Antiphospholipid antibodies (aPL) are mandatory for the diagnosis but are also a risk factor for the antiphospholipid syndrome (APS) clinical manifestations. Lupus anticoagulant (LA), anticardiolipin (aCL), and anti-beta2 glycoprotein I (β2GPI) assays are the formal laboratory classification/diagnostic criteria. Additional nonclassification assays have been suggested; among them, antiphosphatidylserine-prothrombin (aPS/PT) and antidomain 1 β2GPI antibodies are the most promising ones although not yet formally accepted. aPL represent the example of a laboratory test that moved from dichotomous to quantitative results consistent with the idea that reporting quantitative data offers more diagnostic/prognostic information for both vascular and obstetric manifestations. Although the general rule is that the higher the aPL titer, the higher the test likelihood ratio, there is growing evidence that this is not the case for persistent low titers and obstetric events. LA displays the highest diagnostic/prognostic power, although some isolated LAs are apparently not associated with APS manifestations. Moreover, isotype characterization is also critical since IgG aPL are more diagnostic/prognostic than IgA or IgM. aPL are directed against two main autoantigens: β2GPI and PT. However, anti-β2GPI antibodies are more associated with the APS clinical spectrum. In addition, there is evidence that anti-β2GPI domain 1 antibodies display a stronger diagnostic/prognostic value. This finding supports the view that antigen and even epitope characterization represents a further step for improving the assay value. The strategy to improve aPL laboratory characterization is a lesson that can be translated to other autoantibody assays in order to improve our diagnostic and prognostic power.
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Affiliation(s)
- Pier Luigi Meroni
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy
| | - Maria Orietta Borghi
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
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29
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Tomasello R, Giordano G, Romano F, Vaccarino F, Siragusa S, Lucchesi A, Napolitano M. Immune Thrombocytopenia in Antiphospholipid Syndrome: Is It Primary or Secondary? Biomedicines 2021; 9:biomedicines9091170. [PMID: 34572358 PMCID: PMC8472578 DOI: 10.3390/biomedicines9091170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 02/05/2023] Open
Abstract
Antiphospholipid syndrome (APS) is frequently associated with thrombocytopenia, in most cases mild and in the absence of major bleedings. In some patients with a confirmed APS diagnosis, secondary immune thrombocytopenia (ITP) may lead to severe thrombocytopenia with consequent major bleeding. At the same time, the presence of antiphospholipid antibodies (aPL) in patients with a diagnosis of primary ITP has been reported in several studies, although with some specific characteristics especially related to the variety of antigenic targets. Even though it does not enter the APS defining criteria, thrombocytopenia should be regarded as a warning sign of a “high risk” APS and thus thoroughly evaluated. The presence of aPL in patients with ITP should be assessed as well to stratify the risk of paradoxical thrombosis. In detail, besides the high hemorrhagic risk in secondary thrombocytopenia, patients with a co-diagnosis of APS or only antibodies are also at risk of arterial and venous thrombosis. In this narrative review, we discuss the correlation between APS and ITP, the mechanisms behind the above-reported entities, in order to support clinicians to define the most appropriate treatment strategy in these patients, especially when anticoagulant or antiplatelet agents may be needed.
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Affiliation(s)
- Riccardo Tomasello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
| | - Giulio Giordano
- Division of Internal Medicine, Hematology Service, Regional Hospital “A. Cardarelli”, 86100 Campobasso, Italy;
| | - Francesco Romano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
| | - Federica Vaccarino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
| | - Alessandro Lucchesi
- Haematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori “Dino Amadori” (IRST), 47104 Meldola, Italy;
| | - Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
- Correspondence: ; Tel.: +39-0916554519; Fax: +39-0916554503
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30
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How I treat anticoagulant-refractory thrombotic antiphospholipid syndrome. Blood 2021; 137:299-309. [PMID: 32898856 DOI: 10.1182/blood.2020004942] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 09/02/2020] [Indexed: 12/26/2022] Open
Abstract
The standard treatment of thrombotic antiphospholipid syndrome (APS) is lifelong oral anticoagulation with a vitamin K antagonist (VKA), generally warfarin. A minority of patients with APS rethrombose despite seemingly adequate anticoagulation. These patients are deemed anticoagulant refractory. The management of anticoagulant-refractory APS is largely empirical and extrapolated from other clinically similar situations. Further options include increased VKA anticoagulation intensity or alternative antithrombotic strategies, including low-molecular-weight heparin, fondaparinux, the addition of antiplatelet therapy, and consideration of vascular options. Patients with anticoagulant-refractory thrombotic APS may have APS-associated thrombocytopenia, which necessitates balancing the risk of recurrent thrombosis vs bleeding to achieve adequate anticoagulation. The multiple mechanisms involved in the generation of the thrombotic phenotype in APS suggest that anticoagulation alone may not control thrombosis. Thus, other modalities, including adjunctive treatment (hydroxychloroquine, statins, and vitamin D) for APS-related thrombosis, merit consideration, as do immunomodulatory therapy and complement inhibition. Patients with APS may have coexistent systemic lupus erythematosus, which adds to the complexity of managing their thromboembolic disease. However, with attention to detail and judicious application of the limited data, it is possible to minimize the morbidity resulting from anticoagulant-refractory thrombotic APS. Multicenter studies are required to guide the sequence of interventions and their comparative efficacy in patients with anticoagulant-refractory thrombotic APS.
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31
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Kamat S, Kumari M. Repurposing Chloroquine Against Multiple Diseases With Special Attention to SARS-CoV-2 and Associated Toxicity. Front Pharmacol 2021; 12:576093. [PMID: 33912030 PMCID: PMC8072386 DOI: 10.3389/fphar.2021.576093] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022] Open
Abstract
Chloroquine and its derivatives have been used since ages to treat malaria and have also been approved by the FDA to treat autoimmune diseases. The drug employs pH-dependent inhibition of functioning and signalling of the endosome, lysosome and trans-Golgi network, immunomodulatory actions, inhibition of autophagy and interference with receptor binding to treat cancer and many viral diseases. The ongoing pandemic of COVID-19 has brought the whole world on the knees, seeking an urgent hunt for an anti-SARS-CoV-2 drug. Chloroquine has shown to inhibit receptor binding of the viral particles, interferes with their replication and inhibits "cytokine storm". Though multiple modes of actions have been employed by chloroquine against multiple diseases, viral diseases can provide an added advantage to establish the anti-SARS-CoV-2 mechanism, the in vitro and in vivo trials against SARS-CoV-2 have yielded mixed results. The toxicological effects and dosage optimization of chloroquine have been studied for many diseases, though it needs a proper evaluation again as chloroquine is also associated with several toxicities. Moreover, the drug is inexpensive and is readily available in many countries. Though much of the hope has been created by chloroquine and its derivatives against multiple diseases, repurposing it against SARS-CoV-2 requires large scale, collaborative, randomized and unbiased clinical trials to avoid false promises. This review summarizes the use and the mechanism of chloroquine against multiple diseases, its side-effects, mechanisms and the different clinical trials ongoing against "COVID-19".
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Affiliation(s)
| | - Madhuree Kumari
- Department of Biochemistry, Indian Institute of Science, Bengaluru, India
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32
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Fujieda Y, Amengual O. New insights into the pathogenic mechanisms and treatment of arterial thrombosis in antiphospholipid syndrome. Eur J Rheumatol 2021; 8:93-99. [PMID: 33226327 PMCID: PMC8133879 DOI: 10.5152/eurjrheum.2020.20058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/04/2020] [Indexed: 11/22/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic disorder clinically characterized by widespread thrombosis and obstetric complications associated with the persistent presence of antiphospholipid antibodies (aPLs). The persistent presence of aPLs represents a thrombotic risk in APS, which can be stratified according to the aPL profile. Thrombosis occurs in both arteries and veins. Notably, arterial thromboses have a higher recurrence compared with venous thromboses and a tendency for recurrence in the same vascular (arterial) site. Secondary prevention of arterial thrombosis requires more intensive treatment than prevention of venous thrombosis. Data from randomized clinical trials indicated that factor Xa inhibitors should not be recommended for APS. Recurrent thromboses in patients with APS treated with factor Xa inhibitors were mainly arterial, with a high rate of stroke. Dual antiplatelet therapy may have some benefit for preventing the recurrence of arterial thrombosis in patients with APS. This review article describes pathogenic mechanisms, clinical features, risk assessment, and management of arterial thrombosis in patients with APS. Particularly, we discuss how secondary prophylaxis may be a useful approach to reduce the occurrence of arterial thrombosis.
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Affiliation(s)
- Yuichiro Fujieda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Olga Amengual
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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Nasonov EL. Coronavirus disease 2019 (COVID-19) and autoimmunity. RHEUMATOLOGY SCIENCE AND PRACTICE 2021. [DOI: 10.47360/1995-4484-2021-5-30] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The coronavirus 2019 pandemic (coronavirus disease, COVID-19), etiologically related to the SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus-2), has once again reawakened healthcare professionals’ interest towards new clinical and conceptual issues of human immunology and immunopathology. An unprecedented number of clinical trials and fundamental studies of epidemiology, virology, immunology and molecular biology, of the COVID-19 clinical course polymorphism and pharmacotherapy have been conducted within one year since the outbreak of 2019 pandemic, bringing together scientists of almost all biological and physicians of almost all medical specialties. Their joint efforts have resulted in elaboration of several types of vaccines against SARS-CoV-2 infection and, in general, fashioning of more rational approaches to patient management. Also important for COVID-19 management were all clinical trials of biologics and “targeted” anti-inflammatory drugs modulating intracellular cytokine signaling, which have been specifically developed for treatment immune-mediated inflammatory rheumatic disease (IMIRDs) over the past 20 years. It became obvious after a comprehensive analysis of the entire spectrum of clinical manifestations and immunopathological disorders in COVID-19 is accompanied by a wide range of extrapulmonary clinical and laboratory disorders, some of which are characteristic of IMIRDs and other autoimmune and auto-in-flammatory human diseases. All these phenomena substantiated the practice of anti-inflammatory drugs repurposing with off-label use of specific antirheumatic agents for treatment of COVID-19. This paper discusses potential use of glucocorticoids, biologics, JAK inhibitors, etc., blocking the effects of pro-inflammatory cytokines for treatment of COVID-19.
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Affiliation(s)
- E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
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Freeman-Beman L, Ratner S, Kabani N, Neculiseanu E, Ginzler E. COVID-19 Coagulopathy in a Patient With Systemic Lupus Erythematosus and Antiphospholipid Antibodies. J Clin Rheumatol 2021; 27:e60-e61. [PMID: 32947435 DOI: 10.1097/rhu.0000000000001599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Frodlund M, Walhelm T, Dahle C, Sjöwall C. Longitudinal Analysis of Anti-cardiolipin and Anti-β2-glycoprotein-I Antibodies in Recent-Onset Systemic Lupus Erythematosus: A Prospective Study in Swedish Patients. Front Med (Lausanne) 2021; 8:646846. [PMID: 33732724 PMCID: PMC7959716 DOI: 10.3389/fmed.2021.646846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/05/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Anti-phospholipid syndrome (APS) and systemic lupus erythematous (SLE) are autoimmune disorders that often co-occur. Anti-phospholipid antibodies (aPL) are typical of both conditions and may be associated with vascular events and pregnancy-related morbidities. Whereas, aPL-screening is mandatory for individuals with suspected SLE, the clinical value of longitudinal aPL analyses in established SLE is unclear. Methods: We investigated the occurrence and variation of IgG/IgA/IgM anti-cardiolipin (aCL) and anti-β2-glycoprotein-I (anti-β2GPI) antibodies, using both the manufacturer's cut-off and a cut-off based on the 99th percentile of 400 apparently healthy donors, in recent-onset SLE. Furthermore, we evaluated the relationships between aPL levels and SLE/APS manifestations, as well as the pharmacotherapy. Patients with SLE who met validated classification criteria were included in this prospective study (N = 54). Samples were obtained at 0, 6, 12, 24, 36, 48, 60, 72, 84, and 96 months after SLE diagnosis. Results: Depending on the cut-off applied, 61.1 or 44.4% showed a positive result for at least one aPL isotype or the lupus anticoagulant test over time. Median values for all six aPL isotypes numerically decreased from inclusion to last follow-up, but none of the isotypes met statistical significance. Seroconversion (from positive to negative, or the opposite direction) was occasionally seen for both aCL and anti-β2GPI. IgA and IgM anti-β2GPI were the most common isotypes, followed by IgM aCL. Presence of IgG aCL associated significantly with myocardial infarction and miscarriage, and IgG/IgA anti-β2GPI with miscarriage. Conclusion: aPL were common during the first years of SLE. Even though the levels fluctuated over time, the patients tended to remain aPL positive or negative. Repeated aPL testing in the absence of new symptoms seems to be of uncertain value in patients with recent-onset SLE.
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Affiliation(s)
- Martina Frodlund
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Tomas Walhelm
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Charlotte Dahle
- Division of Inflammation and Infection/Clinical Immunology and Transfusion Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Devaux CA, Camoin-Jau L, Mege JL, Raoult D. Can hydroxychloroquine be protective against COVID-19-associated thrombotic events ? JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:37-45. [PMID: 33500211 PMCID: PMC7783458 DOI: 10.1016/j.jmii.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/15/2020] [Accepted: 12/24/2020] [Indexed: 02/06/2023]
Abstract
Although SARS-CoV-2 is considered a lung-tropic virus, severe COVID-19 is not just a viral pulmonary infection, clinically it is a multi-organ pathology with major coagulation abnormalities and thromboembolism events. Recently, antiphospholipid (aPL) antibodies were found increased in a large number of COVID-19 patients. Elevated aPL have been well documented in antiphospholipid syndrome (APS), a systemic autoimmune disorder characterized by recurrent venous or arterial thrombosis and/or obstetrical morbidity. Among treatment regimen of APS, hydroxychloroquine (HCQ) is one of the molecules proposed in the primary prevention of thrombosis and obstetrical morbidity in those patients. Due to its antithrombotic properties documented in APS therapy, HCQ could be considered a good candidate for the prevention of thrombotic events in COVID-19 patients in association with anticoagulant and its repurposing deserves further evaluation.
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Affiliation(s)
- Christian A Devaux
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France; CNRS, Marseille, France.
| | - Laurence Camoin-Jau
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France; Laboratoire D'Hématologie, Hôpital de La Timone, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
| | - Jean-Louis Mege
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Didier Raoult
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
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Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS), more common than once believed, is an autoimmune disease best known for its high risk of incident and recurrent thrombotic events. The approach to treatment potentially differs from treatment of thrombosis in the general population, and this article endeavors to review the latest updates on this topic. RECENT FINDINGS The epidemiology of APS is being increasingly elucidated by large population-based studies, with APS perhaps affecting as many as 1 in 2000 individuals. Vitamin K antagonists, aspirin, and heparinoids continue to have obvious roles in the management of patients with APS. There has recently been intensive study of direct oral anticoagulants in APS, with the most recent randomized studies raising concerns about their inferiority to vitamin K antagonists, at least in some subgroups. Other approaches to treating APS beyond anticoagulants and antiaggregants are also receiving increased attention in mechanistic and preclinical studies with an eye toward future roles in patients with refractory and/or microvascular disease. Pediatric APS is identified as an area in desperate need of additional prospective research. SUMMARY Progress continues to be made in pursuit of improving the lives of individuals afflicted with APS. The most important future directions would seem to involve leveraging modern molecular technologies in order to improve subphenotyping of antiphospholipid antibody-positive individuals. This will help personalize risk profiles and ideally define the optimal approach to therapy based on future risk, rather than past morbid events.
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Karpouzas GA, Ormseth SR, Hernandez E, Bui VL, Budoff MJ. Beta-2-glycoprotein-I IgA antibodies predict coronary plaque progression in rheumatoid arthritis. Semin Arthritis Rheum 2020; 51:20-27. [PMID: 33360226 DOI: 10.1016/j.semarthrit.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/22/2020] [Accepted: 10/16/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate whether anti-Beta-2-Glycoprotein-I (anti-β2GPI) IgA antibodies associate with progression of coronary atherosclerosis and cardiovascular disease (CVD) events in rheumatoid arthritis (RA). METHODS One hundred-fifty patients underwent plaque evaluation (total, non-calcified, mixed and calcified) with coronary computed tomography angiography; 101 were re-imaged within 6.9±0.3 years to assess progression. The Framingham-D'Agostino score assessed cardiovascular risk. Coronary artery calcium (CAC) and segment involvement score quantified plaque burden. RESULTS Anti-β2GPI IgA were seen in 45 (30%) patients. Despite no link to baseline plaque burden, anti-β2GPI IgA associated with segment involvement score increase (adjusted-RR=1.64 [95%CI 1.02-2.63]), CAC change (adjusted-β=0.33 [95%CI 0.002-0.656]) and developing new extensive or obstructive plaque at follow-up (adjusted-OR=4.24 [95%CI 1.30-13.87]). Adding anti-β2GPI IgA to logistic regression models with conventional risk factors predicting plaque progression outcomes increased Area under the receiver-operator curve and improved Net Reclassification and Integrated Discrimination Improvement indices (all P<0.05). In per-segment analyses, anti-β2GPI IgA predicted mixed plaque formation (adjusted-OR=3.20 [95%CI 1.01-10.09]) and lower likelihood of transition of mixed to calcified plaque (adjusted-OR=0.19 [95%CI 0.04-0.96]). Anti-β2GPI IgA moderated the effect of C-reactive protein on CAC change such that C-reactive protein associated with CAC change (β=0.26 [95%CI 0.14-0.38]) and CVD risk (adjusted-HR=1.89 [95%CI 1.02-3.51]) only in anti-β2GPI IgA positive patients. CONCLUSION Anti-β2GPI IgA addition to clinical risk models improved prediction accuracy of CAC, plaque progression and transition to extensive/obstructive disease. They associated with new high-risk mixed plaques and delayed healing to calcified lesions. Anti-β2GPI IgA further modified the effect of inflammation on plaque progression and CVD events.
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Affiliation(s)
- George A Karpouzas
- Division of Rheumatology, Harbor-UCLA Medical Center and Lundquist Institute for Biomedical Innovation, 1124 West Carson Street, Building E4-R17, Torrance, CA 90502, USA.
| | - Sarah R Ormseth
- Division of Rheumatology, Harbor-UCLA Medical Center and Lundquist Institute for Biomedical Innovation, 1124 West Carson Street, Building E4-R17, Torrance, CA 90502, USA
| | - Elizabeth Hernandez
- Division of Rheumatology, Harbor-UCLA Medical Center and Lundquist Institute for Biomedical Innovation, 1124 West Carson Street, Building E4-R17, Torrance, CA 90502, USA
| | - Viet L Bui
- Division of Rheumatology, Harbor-UCLA Medical Center and Lundquist Institute for Biomedical Innovation, 1124 West Carson Street, Building E4-R17, Torrance, CA 90502, USA
| | - Matthew J Budoff
- Division of Cardiology, Harbor-UCLA Medical Center and Lundquist Institute for Biomedical Innovation, Torrance, CA, USA
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Cheng C, Cheng GY, Denas G, Pengo V. Arterial thrombosis in antiphospholipid syndrome (APS): Clinical approach and treatment. A systematic review. Blood Rev 2020; 48:100788. [PMID: 33341301 DOI: 10.1016/j.blre.2020.100788] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/17/2020] [Accepted: 12/08/2020] [Indexed: 12/17/2022]
Abstract
Thrombotic Antiphospholipid Syndrome (APS) is a condition affecting young individuals in whom a thromboembolic event occurs in the presence of circulating antiphospholipid antibodies (aPL). An extensive body of literature has covered the most common clinical presentation of the syndrome, venous thromboembolism. Arterial thrombosis in APS, a lesser clinical expression, is less studied. This review will concentrate on the body of literature concerning pathogenesis, clinical presentation and management of arterial thrombosis in APS.
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Affiliation(s)
- Chunyan Cheng
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Gang-Yi Cheng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Gentian Denas
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy.
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Medina G, Cimé Aké EA, Vera-Lastra O, Saavedra MÁ, Cruz-Domínguez MDP, Amigo MC, Jara LJ. Damage index for antiphospholipid syndrome during long term follow-up: Correlation between organ damage accrual and quality of life. Lupus 2020; 30:96-102. [PMID: 33176566 DOI: 10.1177/0961203320970651] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Consequences of organ damage in primary antiphospholipid syndrome (PAPS) are diverse, our aim was to determine organ damage over time and the correlation of organ damage accrual with health-related quality of life (HRQoL) in PAPS. METHODS First phase: retrospective cohort applying Damage Index for Antiphospholipid Syndrome (DIAPS) at 1, 5, 10, 20 years, or longer since diagnosis. Second phase: cross-sectional study, assessing HRQoL by the Medical Outcomes Study Short Form 36 (SF-36), and organ damage accrual. Descriptive statistics and Spearman correlation coefficient were used. RESULTS Sixty-seven patients were included, mean follow-up:15 years. Deep vein thrombosis prevailed (71.6%), pulmonary embolism (35.8%) and stroke (32.8%). Organ damage was found in 98.5%, with a cumulative DIAPS value of 3, with greater involvement in the neuropsychiatric and peripheral vascular domains. Regarding HRQoL, deterioration in the physical component summary (PCS) was found in 89.6%. Organ damage accrual correlated inversely and significantly with all the SF-36 domains, mainly with the total score and PCS. Body pain and PCS correlated the most (rho = -0.503, rho = -0.475). CONCLUSIONS Organ damage accrual impaired HRQoL in PAPS. Secondary thromboprophylxis through adequate systemic management and control of cardiovascular risk factors are necessary to prevent further impairment.
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Affiliation(s)
- Gabriela Medina
- Translational Research Unit, Hospital de Especialidades Centro Médico La Raza, IMSS, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Erik Antonio Cimé Aké
- Internal Medicine Department, Hospital de Especialidades Centro Médico La Raza, IMSS, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Olga Vera-Lastra
- Internal Medicine Department, Hospital de Especialidades Centro Médico La Raza, IMSS, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Miguel Ángel Saavedra
- Rheumatology Department, Hospital de Especialidades Centro Médico La Raza, IMSS, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - María Del Pilar Cruz-Domínguez
- Research Division, Hospital de Especialidades Centro Médico La Raza, IMSS, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | | | - Luis J Jara
- Direction of Education and Research, Hospital de Especialidades Centro Médico La Raza, IMSS, Universidad Nacional Autónoma de México, Mexico City, Mexico
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Abstract
Antiphospholipid syndrome is one of the more common acquired causes of hypercoagulability. Its major presentations are thrombotic (arterial, venous, or microvascular) and pregnancy morbidity (miscarriages, late intrauterine fetal demise, and severe pre-eclampsia). Classification criteria include 3 different antiphospholipid antibodies: lupus anticoagulant, anticardiolipin, and anti-beta 2 glycoprotein I. Management includes both preventive strategies (low-dose aspirin, hydroxychloroquine) and long-term anticoagulation after thrombosis.
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Affiliation(s)
- Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Cohen H, Cuadrado MJ, Erkan D, Duarte-Garcia A, Isenberg DA, Knight JS, Ortel TL, Rahman A, Salmon JE, Tektonidou MG, Williams DJ, Willis R, Woller SC, Andrade D. 16th International Congress on Antiphospholipid Antibodies Task Force Report on Antiphospholipid Syndrome Treatment Trends. Lupus 2020; 29:1571-1593. [PMID: 33100166 PMCID: PMC7658424 DOI: 10.1177/0961203320950461] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 07/24/2020] [Indexed: 12/13/2022]
Abstract
Antiphospholipid syndrome (APS), an acquired autoimmune thrombophilia, is characterised by thrombosis and/or pregnancy morbidity in association with persistent antiphospholipid antibodies. The 16th International Congress on Antiphospholipid Antibodies Task Force on APS Treatment Trends reviewed the current status with regard to existing and novel treatment trends for APS, which is the focus of this Task Force report. The report addresses current treatments and developments since the last report, on the use of direct oral anticoagulants in patients with APS, antiplatelet agents, adjunctive therapies (hydroxychloroquine, statins and vitamin D), targeted treatment including rituximab, belimumab, and anti-TNF agents, complement inhibition and drugs based on peptides of beta-2-glycoprotein I. In addition, the report summarises potential new players, including coenzyme Q10, adenosine receptor agonists and adenosine potentiation. In each case, the report provides recommendations for clinicians, based on the current state of the art, and suggests a clinical research agenda. The initiation and development of appropriate clinical studies requires a focus on devising suitable outcome measures, including a disease activity index, an optimal damage index, and a specific quality of life index.
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Affiliation(s)
- Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University
College London, London, UK
- University College London Hospitals NHS Foundation Trust,
London, UK
| | - Maria J Cuadrado
- Rheumatology Department, Clinica Universidad de Navarra, Madrid,
Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital
for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Ali Duarte-Garcia
- Division of Rheumatology, Department of Internal Medicine, Mayo
Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health
Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Isenberg
- University College London Hospitals NHS Foundation Trust,
London, UK
- Centre for Rheumatology, Division of Medicine, University
College London, London, UK
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor,
Michigan, USA
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine, and Department
of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Anisur Rahman
- Centre for Rheumatology, Division of Medicine, University
College London, London, UK
| | - Jane E Salmon
- Division of Rheumatology, Hospital for Special surgery, Weill
Cornell Medicine, New York, NY, USA
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, National
and Kapodistrian University of Athens, Athens, Greece
| | - David J Williams
- University College London Hospitals NHS Foundation Trust,
London, UK
- UCL EGA Institute for Women’s Health, University College
London, London, UK
| | - Rohan Willis
- Antiphospholipid Standardization Laboratory, University of
Texas Medical Branch, Galveston, TX, USA
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray
UT; Division of General Internal Medicine, University of Utah School of
Medicine, Salt Lake City, UT, USA
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Radin M, Cecchi I, Rubini E, Foddai SG, Barinotti A, Menegatti E, Roccatello D, Sciascia S. Treatment of antiphospholipid syndrome. Clin Immunol 2020; 221:108597. [PMID: 32961331 DOI: 10.1016/j.clim.2020.108597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/05/2020] [Accepted: 09/15/2020] [Indexed: 12/11/2022]
Abstract
Antiphospholipid syndrome (APS) is the most common acquired thrombophilia. The clinical manifestations of APS are mainly vascular thrombosis (venous and/or arterial) and/or recurrent pregnancy morbidity with the concomitant persistent presence of antiphospholipid antibodies (aPL). Therefore, the goals of the treatment of patients with APS are reducing the pregnancy morbidity and/or the prevention of thrombotic events during the follow-up. Optimal treatment of APS has long been discussed, due to the heterogeneity of the clinical manifestations and the consequent plurality in the medical specialties involved in managing this condition. This review summarizes the available evidence on primary thromboprophylaxis in aPL-positive individuals with no prior thrombotic events, secondary prophylaxis in patients with positive history for thrombotic events, the management of refractory or difficult cases and the current strategies for the management of APS during pregnancy.
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Affiliation(s)
- Massimo Radin
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Silvia Grazietta Foddai
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Alice Barinotti
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Elisa Menegatti
- School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy.
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Zen M, Loredo Martinez M, Benvenuti F, Gatto M, Saccon F, Larosa M, Iaccarino L, Doria A. Prevalence, outcome and management of patients with SLE and secondary antiphospholipid antibody syndrome after aPL seroconversion. Rheumatology (Oxford) 2020; 60:1313-1320. [DOI: 10.1093/rheumatology/keaa463] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/21/2020] [Indexed: 02/06/2023] Open
Abstract
Abstract
Objective
The withdrawal of oral anticoagulation (OAC) in patients with SLE and secondary aPL syndrome (SAPS) who become seronegative has not been clearly investigated to date. Our aim was to evaluate the prevalence of aPL seroconversion and the prognosis of SLE patients with SAPS who withdrew OAC after aPL negativization.
Methods
We retrospectively analysed data of all SLE patients (ACR criteria) with SAPS (Sydney criteria) prospectively followed-up in our clinic. aPL seroconversion was defined as negativization of lupus anticoagulant, aCL, and anti-β2glycoprotein-1 antibodies on two or more consecutive measurements, at least 12 weeks apart. OAC discontinuation was defined as the definitive withdrawal of all anticoagulants.
Results
Fifty-five out of 513 (10.7%) SLE patients had vascular SAPS. Sixteen patients (29.1%) became aPL seronegative during follow-up. Immunosuppressive therapy predicted aPL negativization (odds ratio 5.211, 95%CI 1.341, 20.243), whereas APS diagnosis prior to that of SLE (odds ratio 0.078, 95%CI 0.008, 0.799) and triple-positive profile (odds ratio 0.264, 95%CI 0.115, 0.609) were negative predictors of aPL negativization. OAC was discontinued in 13/55 patients (23.6%), after a median follow-up of 45 months (range 1–276) from aPL seroconversion. SLE-related modifiable risk factors for thrombosis were observed in 10/13 patients (77%) at the time of the thrombotic event. No thrombotic recurrences were observed during a mean follow-up time of 44 (19) months from OAC discontinuation.
Conclusions
Our results suggest that OAC can be safely discontinued in SLE patients who became persistently seronegative for aPL, at least when aPL-related thrombotic events occurred in presence of other thrombotic risk factors.
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Affiliation(s)
- Margherita Zen
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Marta Loredo Martinez
- Division of Rheumatology, Lozano Blesa University Clinical Hospital, Zaragoza, Spain
| | - Francesco Benvenuti
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Francesca Saccon
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Maddalena Larosa
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Luca Iaccarino
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
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Cohen H, Sayar Z, Efthymiou M, Gaspar P, Richards T, Isenberg D. Management of anticoagulant-refractory thrombotic antiphospholipid syndrome. LANCET HAEMATOLOGY 2020; 7:e613-e623. [PMID: 32735839 DOI: 10.1016/s2352-3026(20)30116-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/27/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
Abstract
Lifelong anticoagulation with warfarin or alternative vitamin K antagonist is the standard anticoagulant treatment for thrombotic antiphospholipid syndrome. Anticoagulant-refractory thrombotic antiphospholipid syndrome can be broadly defined as breakthrough thrombosis while on standard oral anticoagulation treatment and its management is a major challenge given the serious nature of the thrombotic disease observed, which has become refractory to oral anticoagulation. The factors (genetic and cellular) that cause anticoagulant-refractory thrombotic antiphospholipid syndrome are now better understood. However, efforts to use this greater understanding have not yet transformed the capacity to treat it successfully in many patients. In this Viewpoint, we review the factors that are likely to be contributing to the cause of this syndrome and consider how they might be modified or inhibited. We also discuss management, including general strategies to minimise thrombotic risk, intensification of anticoagulation, addition of an antiplatelet agent, adjunctive treatment for thrombosis, immunomodulatory therapy, complement inhibition, vascular options, and future potential therapeutic targets.
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Affiliation(s)
- Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK; Haemostasis Research Unit, Department of Haematology, University College London, London, UK.
| | - Zara Sayar
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Pedro Gaspar
- Department of Internal Medicine, Hospital of Santa Maria, Lisbon, Portugal
| | - Toby Richards
- Department of Vascular Surgery, University of Western Australia, Perth, WA, Australia
| | - David Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Bettiol A, Pregnolato F, Sciascia S, Emmi G, Prisco D, Meroni PL. Association of subcutaneous belimumab and long-term antimalarial treatment reduces antiphospholipid antibodies levels in systemic lupus erythematosus: post-hoc analysis of a randomised placebo-controlled trial-comment on: 'Effect of belimumab treatment on antiphospholipid antibody levels: post-hoc analysis based on two randomised placebo-controlled trials in systemic lupus erythematosus' by Chatzidionysiou et al. Ann Rheum Dis 2020; 81:e140. [PMID: 32753414 DOI: 10.1136/annrheumdis-2020-218377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Alessandra Bettiol
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Firenze, Italy
| | - Francesca Pregnolato
- Experimental Laboratory of Immuno-rheumatology, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Italy
| | - Savino Sciascia
- Dipartimento di Malattie Rare, Immunologiche, Ematologiche ed Immunoematologiche, Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare, Struttura Complessa a Direzione Universitaria di Immunologia Clinica, Ospedale Torino Nord Emergenza San G. Bosco ed Università di Torino, Torino, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immuno-rheumatology, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Italy
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Chatzidionysiou K, Samoli E, Sfikakis PP, Tektonidou MG. Response to: ‘Association of subcutaneous belimumab and long-term antimalarial treatment reduces antiphospholipid antibodies levels in systemic lupus erythematosus: post-hoc analysis of a randomised placebo-controlled trial–comment on: ‘Effect of belimumab treatment on antiphospholipid antibody levels: post-hoc analysis based on two randomised placebo-controlled trials in systemic lupus erythematosus’ by Chatzidionysiou et al’ by Bettiol et al. Ann Rheum Dis 2020; 81:e141. [DOI: 10.1136/annrheumdis-2020-218444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/04/2022]
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Capucci A, Santarelli A, Bartolomei M, Paolizzi C, Biagetti C, Dappozzo A, Piovaccari G. Low hospitalization rate without severe arrhythmias: a prospective survey on 350 patients early home treated with hydroxychloroquine during COVID-19 pandemic. J Cardiovasc Med (Hagerstown) 2020; 21:922-923. [PMID: 32740441 DOI: 10.2459/jcm.0000000000001061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Alessandro Capucci
- Specialization School of Cardiology, Università Politecnica delle Marche, Ancona
| | | | | | | | - Carlo Biagetti
- Infectious Disease Unit of Rimini, AUSL Romagna, Rimini, Italy
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Elbagir S, Elshafie AI, Elagib EM, Mohammed NA, Aledrissy MI, Manivel VA, Pertsinidou E, Nur MA, Gunnarsson I, Svenungsson E, Rönnelid J. High IgA antiphospholipid autoantibodies in healthy Sudanese explain the increased prevalence among Sudanese compared to Swedish systemic lupus erythematosus patients. Lupus 2020; 29:1412-1422. [PMID: 32741301 PMCID: PMC7536526 DOI: 10.1177/0961203320945387] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objectives IgA antiphospholipid antibodies (aPL) are prevalent in systemic lupus
erythematosus (SLE) patients of African American, Afro-Caribbean and South
African origin. Nevertheless, data from North Africa are lacking, and most
studies use manufacturer-suggested cut-offs based on Caucasian controls.
Therefore, we compared aPL isotypes in Sudanese and Swedish SLE patients
using nation-based cut-offs. Methods Consecutive SLE patients and age- and sex-matched controls from Sudan
(N = 115/106) and Sweden (N = 340/318)
were included. All patients fulfilled the 1982 American College of
Rheumatology SLE classification criteria. Antiphospholipid syndrome–related
events were obtained from patients’ records. IgA/G/M anticardiolipin and
anti-β2 glycoprotein I (β2GPI) were analysed with
two independent assays. IgA anti-β2GPI domain 1 (D1) was also
investigated. Manufacturers’ cut-offs and the 95th and 99th percentile
cut-offs based on national controls were used. Results Sudanese patients and controls had higher levels and were more often positive
for IgA aPL than Swedes when using manufacturers’ cut-offs. In contrast,
using national cut-offs, the increase in IgA aPL among Sudanese patients was
lost. Occurrence of IgA anti-D1 did not differ between the countries. Venous
thromboses were less common among Sudanese patients and did not associate
with aPL. No clinical associations were observed with IgA
anti-β2GPI in Sudanese patients. Thromboses in Swedes were
associated with IgG/M aPL. Fetal loss was associated with aPL in both
cohorts. Conclusions IgA anti-β2GPI prevalence was higher among Sudanese compared to
Swedish patients when manufacturers’ cut-offs were used. This situation was
reversed when applying national cut-offs. Anti-D1 was not increased in
Sudanese patients. Previous studies on populations of African origin, which
demonstrate a high prevalence of IgA aPL positivity, should be re-evaluated
using a similar cut-off approach.
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Affiliation(s)
- Sahwa Elbagir
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Amir I Elshafie
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | | | | | - Vivek Anand Manivel
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Musa Am Nur
- Rheumatology Unit, Alribat University Hospital, Khartoum, Sudan
| | - Iva Gunnarsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Rönnelid
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Quiros Roldan E, Biasiotto G, Magro P, Zanella I. The possible mechanisms of action of 4-aminoquinolines (chloroquine/hydroxychloroquine) against Sars-Cov-2 infection (COVID-19): A role for iron homeostasis? Pharmacol Res 2020; 158:104904. [PMID: 32430286 PMCID: PMC7217799 DOI: 10.1016/j.phrs.2020.104904] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 02/06/2023]
Abstract
The anti-malarial drugs chloroquine (CQ) and primarily the less toxic hydroxychloroquine (HCQ) are currently used to treat autoimmune diseases for their immunomodulatory and anti-thrombotic properties. They have also been proposed for the treatment of several viral infections, due to their anti-viral effects in cell cultures and animal models, and, currently, for the treatment of coronavirus disease 2019 (COVID-19), the pandemic severe acute respiratory syndrome caused by coronavirus 2 (Sars-Cov-2) infection that is spreading all over the world. Although in some recent studies a clinical improvement in COVID-19 patients has been observed, the clinical efficacy of CQ and HCQ in COVID-19 has yet to be proven with randomized controlled studies, many of which are currently ongoing, also considering pharmacokinetics, optimal dosing regimen, therapeutic level and duration of treatment and taking into account patients with different severity degrees of disease. Here we review what is currently known on the mechanisms of action of CQ and HCQ as anti-viral, anti-inflammatory and anti-thrombotic drugs and discuss the up-to-date experimental evidence on the potential mechanisms of action of CQ/HCQ in Sars-Cov2 infection and the current clinical knowledge on their efficacy in the treatment of COVID-19 patients. Given the role of iron in several human viral infections, we also propose a different insight into a number of CQ and HCQ pharmacological effects, suggesting a potential involvement of iron homeostasis in Sars-Cov-2 infection and COVID-19 clinical course.
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Affiliation(s)
- Eugenia Quiros Roldan
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili di Brescia, Brescia, Italy
| | - Giorgio Biasiotto
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy; Clinical Chemistry Laboratory, Cytogenetics and Molecular Genetics Section, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Paola Magro
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili di Brescia, Brescia, Italy
| | - Isabella Zanella
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy; Clinical Chemistry Laboratory, Cytogenetics and Molecular Genetics Section, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy.
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