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Depietri L, Veropalumbo MR, Leone MC, Ghirarduzzi A. Antiphospholipid Syndrome: State of the Art of Clinical Management. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07496-3. [PMID: 37572208 DOI: 10.1007/s10557-023-07496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/14/2023]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder clinically characterized by recurrent arterial and venous thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies. Currently, treatment is mainly focused on anticoagulation, but therapies targeting mechanisms involved in APS autoimmune pathogenesis could play an important role in specific settings. An evidence-based therapeutic approach is limited by the broad clinical spectrum of the syndrome and the nature of a "rare disease" that makes it difficult to carry out well-designed prospective studies. Vitamin K antagonists (AVK), notably warfarin, are the standard treatment for preventing recurrent venous thrombosis and perhaps also arterial thrombosis. Direct oral anticoagulants (DOACs) are not recommended at least in patients with triple positivity APS. Treatment options for the prevention of pregnancy complications in obstetric APS, as combined use of aspirin and heparin, low-dose prednisolone, hydroxychloroquine, intravenous immunoglobulin (IVIG), may improve pregnancy outcome. The catastrophic antiphospholipid syndrome (CAPS) is the most severe form of APS with acute multiple organ involvement and small vessel thrombosis. Glucocorticoids, heparin, plasma exchange or IVIG, rituximab, or eculizumab must be added to concurrent treatment of precipitating factors (e.g. infections) as rescue therapies. Finally, it has been observed that SARS COV2 infection may produce vascular complications mimicking the clinical and pathophysiological features of APS and particularly of CAPS. From this point of view, attention has been focused on the "protective" role of anticoagulant therapy in preventing thrombotic complication when these clinical conditions coexist.
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Affiliation(s)
- Luca Depietri
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Maria Rosaria Veropalumbo
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Maria Cristina Leone
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Angelo Ghirarduzzi
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
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2
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Shah BB, Shankar A, Kumar V, Kumar S, Malik UA, Majeed A, Kumar V, Berkha, Suman, Kumar S, Netha A, Subedi S, Ahmed S. Direct oral anticoagulants vs. vitamin K antagonists in patients with antiphospholipid syndrome: a systematic review and meta-analysis. Ann Med Surg (Lond) 2023; 85:3574-3582. [PMID: 37427194 PMCID: PMC10328675 DOI: 10.1097/ms9.0000000000000903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/14/2023] [Indexed: 10/31/2023] Open
Abstract
UNLABELLED Optimal treatment regimen for patients with antiphospholipid syndrome (APS) remain unclear. Therefore, the authors sought to compare the outcomes of vitamin K antagonists (VKAs) vs. direct oral anticoagulants (DOACs) in patients with APS. METHODS MEDLINE, Embase, and Cochrane Central databases were searched for randomized controlled trials comparing efficacy and safety of VKAs and DOACs inhibitors in patients with APS. Recurrent thrombosis, all-cause mortality, stroke, adverse reactions, and bleeding were among outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95% CIs. RESULTS The analysis included 625 patients from four randomized controlled trials and one post hoc analysis. Meta-analysis showed statistically non-significant difference between DOACs inhibitors and VKAs in the recurrent thrombosis risk (arterial or venous) [RR 2.77 (95%, CI 0.79, 9.65); P=0.11, I2=50%]. Consistent results were revealed among patients with the previous history of arterial thrombosis [RR 2.76 (95% CI 0.93, 8.16); P=0.75, I2=0%], venous thrombosis [RR 1.71 (95% CI 0.60, 4.84); P=0.31, I2=15%] and patients who were triple antiphospholipid positive [RR 4.12 (95% CI 0.46, 37.10); P=0.21, I2=58%]. DOACs inhibitors were significantly associated with increased risk of stroke [RR 8.51 (95% CI 2.35, 3.82); P=0.47, I2=0%]. CONCLUSION DOACs exhibited increased risk of stroke among patients with APS. In addition, although not significant, the higher RRs among patients on DOACs may indicate higher risk of thrombotic events associated with DOACs.
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Affiliation(s)
| | - Abhirami Shankar
- Department of Internal Medicine, West Anaheim Medical Centre, Anaheim, CA
| | - Vinesh Kumar
- Department of Medicine, Chandka Medical College, Larkana
| | - Sumeet Kumar
- Department of Internal Medicine, Dow University of Health Sciences
| | | | - Abdul Majeed
- Department of Medicine, Liaquat College of Medicine and Dentistry
| | | | - Berkha
- Department of Medicine, Peoples Medical College, Nawabshah, Pakistan
| | - Suman
- Department of Medicine, Chandka Medical College, Larkana
| | - Sumeet Kumar
- Medicine, Liaquat University of Medical & Health Sciences, Karachi
| | - Aadarsh Netha
- Department of Medicine, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
| | - Sonika Subedi
- Department of Medicine, Chitwan Medical College, Bharatpur, Nepal
| | - Shoaib Ahmed
- Department of Medicine, Kabul Medical University, Kabul, Afghanistan
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3
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Bezerra AS, Wroclawski CK, Lorber GR, Filho CC. Secondary vasculopathy due to catastrophic antiphospholipid syndrome. Hematol Transfus Cell Ther 2023; 45:406-409. [PMID: 34836847 PMCID: PMC10499566 DOI: 10.1016/j.htct.2021.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/03/2021] [Accepted: 09/26/2021] [Indexed: 11/16/2022] Open
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4
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Attachaipanich T, Aungsusiripong A, Piriyakhuntorn P, Hantrakool S, Rattarittamrong E, Rattanathammethee T, Tantiworawit A, Norasetthada L, Chai-Adisaksopha C. Antithrombotic therapy in antiphospholipid syndrome with arterial thrombosis: a systematic review and network meta-analysis. Front Med (Lausanne) 2023; 10:1196800. [PMID: 37396906 PMCID: PMC10311019 DOI: 10.3389/fmed.2023.1196800] [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: 03/30/2023] [Accepted: 05/26/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction The optimal secondary thromboprophylactic strategies for patients with antiphospholipid syndrome (APS) and arterial thrombosis remain controversial. This study aimed to evaluate the comparative efficacy and safety of various antithrombotic strategies in APS with arterial thrombosis. Methods A comprehensive literature search was conducted using OVID MEDLINE, EMBASE, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) from inception until 30 September 2022, with no language restrictions. The inclusion criteria for eligible studies were as follows: inclusion of APS patients with arterial thrombosis, treatment with either antiplatelet agents, warfarin, direct oral anticoagulants (DOACs), or a combination of these therapies, and reporting of recurrent thrombotic events. Results We conducted a frequentist random-effects network meta-analysis (NMA) involving 13 studies with a total of 719 participants, comprising six randomized and seven non-randomized studies. In comparison to single antiplatelet therapy (SAPT), the combined use of antiplatelet and warfarin demonstrated a significant reduction in the risk of recurrent overall thrombosis, with a risk ratio (RR) of 0.41 (95% CI 0.20 to 0.85). Dual antiplatelet therapy (DAPT) showed a lower risk of recurrent arterial thrombosis compared to SAPT although the difference did not reach statistical significance, with an RR of 0.29 (95% CI 0.08 to 1.07). DOAC was associated with a significant increase in the risk of recurrent arterial thrombosis, with an RR of 4.06 (95% CI 1.33 to 12.40) when compared to SAPT. There was no significant difference in major bleeding among various antithrombotic strategies. Discussion Based on this NMA, the combination of warfarin and antiplatelet therapy appears to be an effective approach in preventing recurrent overall thrombosis in APS patients with a history of arterial thrombosis. While DAPT may also show promise in preventing recurrent arterial thrombosis, further studies are needed to confirm its efficacy. Conversely, the use of DOACs was found to significantly increase the risk of recurrent arterial thrombosis.
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Affiliation(s)
- Tanawat Attachaipanich
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Aimpat Aungsusiripong
- Department of Otorhinolaryngology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pokpong Piriyakhuntorn
- Division of Hematology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sasinee Hantrakool
- Division of Hematology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Ekarat Rattarittamrong
- Division of Hematology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Adisak Tantiworawit
- Division of Hematology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Lalita Norasetthada
- Division of Hematology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chatree Chai-Adisaksopha
- Division of Hematology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
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5
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Girón-Ortega JA, Girón-González JA. Direct-acting oral anticoagulants in antiphospholipid syndrome: A systematic review. Med Clin (Barc) 2023:S0025-7753(23)00157-4. [PMID: 37105842 DOI: 10.1016/j.medcli.2023.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023]
Abstract
The objective of the systematic review is to analyze the efficacy of direct-acting oral anticoagulants (DOAC) in the prophylaxis of thrombosis in antiphospholipid syndrome (APS). We searched for clinical trials, cohort studies and meta-analyses published from January 1, 2012 to September 30, 2022. Articles that analyzed the efficacy of DOAC in the prevention of thrombosis recurrence, with or without comparison with antivitamin K (VKA) drugs, were selected. DOACs, specifically rivaroxaban and apixaban, were significantly less effective than VKAs in preventing recurrence of thrombosis in patients with APS and prior arterial thrombosis or the concomitant presence of two or three different antiphospholipid antibodies. The proportion of patients with severe bleeding as side effect are similar in those treated with DOAC and with VKA. The results argue against the use of DOAC in the treatment of patients with thrombotic APS.
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Affiliation(s)
| | - José Antonio Girón-González
- Servicio de Medicina Interna, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación Biomédica de Cádiz (INiBICA), Cádiz, España
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6
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Sayar Z, Burke S, Mittal P, Cohen H. The use of fondaparinux and rituximab for recurrent thrombotic events in antiphospholipid syndrome. Lupus 2022; 31:1485-1490. [PMID: 36074077 PMCID: PMC9580031 DOI: 10.1177/09612033221122147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Limited evidence exists to guide the management of recurrent thrombosis occurring despite therapeutic anticoagulation in patients with thrombotic antiphospholipid syndrome (APS). In this case series, fondaparinux, with or without an antiplatelet agent, provided an effective and safe option in three patients with thrombotic APS, all two triple and one single positive for antiphospholipid antibodies, who had recurrent venous and/or arterial thromboembolism. Rituximab was also used in all patients. Recurrent events occurred despite therapeutic anticoagulation, including at high-intensity, with warfarin and subsequent low-molecular-weight heparin. There were no major bleeding events. Adjunctive therapies used for thrombosis included catheter-directed thrombolysis and rituximab.
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Affiliation(s)
- Zara Sayar
- Department of Haematology, 4919University College London Hospitals NHS Foundation Trust, London, UK.,Department of Haematology, Whittington Health NHS Trust, London, UK
| | - Shoshana Burke
- Department of Haematology, 4919University College London Hospitals NHS Foundation Trust, London, UK
| | - Prabal Mittal
- Department of Haematology, 4919University College London Hospitals NHS Foundation Trust, London, UK.,Haemostasis Research Unit, Department of Haematology, 4919University College London, London, UK
| | - Hannah Cohen
- Department of Haematology, 4919University College London Hospitals NHS Foundation Trust, London, UK.,Haemostasis Research Unit, Department of Haematology, 4919University College London, London, UK
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7
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Gan Y, Zhao Y, Li G, Ye H, Zhou Y, Hou C, Wang L, Guo J, Li C. Risk Factors and Outcomes of Acute Myocardial Infarction in a Cohort of Antiphospholipid Syndrome. Front Cardiovasc Med 2022; 9:871011. [PMID: 35865377 PMCID: PMC9294316 DOI: 10.3389/fcvm.2022.871011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Antiphospholipid syndrome (APS) is a disorder associated with thromboembolic diseases, including acute myocardial infarction (AMI). Given that AMI is a relatively common condition with poor prognostic features, identification of risk factors for AMI in APS is important. Methods A retrospective cohort study was performed consisting of 332 patients with APS, and 239 patients with thrombotic APS were finally included. Patients were followed up in the outpatient department for 5 years. Clinical data and laboratory parameters were analyzed to identify the risk factors for AMI in APS. The primary and secondary clinical outcomes were all-cause mortality and recurrence of thrombosis, respectively. Results AMI was observed in 12.1% (29/239) of patients with APS. Compared to patients without AMI, patients with AMI had multiple organ thrombosis (55.1 vs. 34.3%, p = 0.029), recurrent thrombosis (58.6 vs. 34.3%, p = 0.011), a higher incidence of atherosclerosis (62.1 vs. 23.8%, p < 0.001), higher neutrophil count (×109/L) [4.68 (3.25, 8.17) vs. 3.71 (2.64, 5.80), p = 0.036], longer QT interval (ms) [438 ms (423, 454) vs. 425 ms (410, 446), p = 0.016], and fewer venous thrombosis events (27.6 vs. 63.3%, p < 0.001). Multivariate logistic regression analysis (adjusted for age and gender) identified several factors that were positively associated with AMI, including multiple organ thrombosis [odds ratio (OR) 8.862, 95% confidence interval (CI): 1.817–43.212, p = 0.007), atherosclerosis (OR 5.397, 95%CI: 1.943–14.994, p = 0.001), and elevated neutrophil count (>6.3 ×109/L) (OR 3.271, 95%CI: 1.268–8.440, p = 0.014). The venous thrombosis was negatively associated with AMI (OR 0.106, 95%CI: 0.036–0.314, p < 0.001). Kaplan–Meier analysis revealed that the recurrence rates of arterial thrombosis differed significantly between patients with AMI and those without AMI [hazard ratio (HR) = 3.307, p = 0.038]. Conclusion Atherosclerosis, multiple organ thrombosis, an increased number of neutrophils are variables positively associated with AMI in APS, and venous thrombosis had a negative association with AMI. AMI only predicts the subsequent recurrence of arterial thrombosis. These findings suggest that distinct pathophysiological mechanisms may exist and contribute to the development of venous or arterial thrombotic APS.
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Affiliation(s)
- Yuzhou Gan
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
| | - Yawei Zhao
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
- Department of Rheumatology and Immunology, Luohe Central Hospital, Luohe, China
| | - Gongming Li
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
- Department of Rheumatology, Linyi Traditional Chinese Medicine Hospital, Linyi, China
| | - Hua Ye
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
| | - Yunshan Zhou
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
| | - Chang Hou
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Lan Wang
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Jianping Guo
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
| | - Chun Li
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
- *Correspondence: Chun Li
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8
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Dabigatran in Cerebral Sinus Vein Thrombosis and Thrombophilia. LIFE (BASEL, SWITZERLAND) 2022; 12:life12070970. [PMID: 35888060 PMCID: PMC9316430 DOI: 10.3390/life12070970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022]
Abstract
Background and Purpose: Thrombophilic gene alterations are a major risk factor for cerebral sinus vein thrombosis (CSVT). Up to 30% of all patients with cerebral sinus vein thrombosis (CSVT) are found to have thrombophilic defects such as prothrombin mutation (PTM) or factor V Leiden (FVL). Their repercussions on the plasma levels of dabigatran etexilate are unclear. In this prospective case–control study, we aimed to investigate whether thrombophilia in CSVT has an influence on dabigatran peak-plasma levels. Methods: We monitored 10 patients over 12 months with acute CSVT, genetic thrombophilia with off-label use of dabigatran etexilate 150 mg twice a day and measured dabigatran peak-plasma levels and radiological outcome. We also monitored patients without genetic thrombophilia with dabigatran etexilate 150 mg twice a day and compared the efficiency and dabigatran peak-plasma levels. Results: Patients with homozygote PTM had significantly lower dabigatran peak concentration compared to patients with FVL or the control group (23 ± 4.2 vs. 152.3 ± 27.5 and 159.6 ± 63.08; p-value ≤ 0.05) There was no significant difference in dabigatran etexilate plasma levels between the heterozygote PTM group compared to patients with FVL or the control group (p = 0.29). There was no correlation between dabigatran peak concentration and delayed thrombus dissolution. Conclusions: Dabigatran peak concentration was stable in patients with heterozygote FVL and heterozygote PTM, but not in homozygote PTM, compared to controls. Genetic screening for thrombophilia in patients after CSVT may be useful to make patient tailored therapeutic decisions regarding oral anticoagulation and may decrease thrombotic events.
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9
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Koval N, Alves M, Plácido R, Almeida AG, Fonseca JE, Ferreira JJ, Pinto FJ, Caldeira D. Direct oral anticoagulants versus vitamin K antagonists in patients with antiphospholipid syndrome: systematic review and meta-analysis. RMD Open 2021; 7:rmdopen-2021-001678. [PMID: 34253684 PMCID: PMC8276293 DOI: 10.1136/rmdopen-2021-001678] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
Background Despite vitamin K antagonists (VKA) being the gold standard in the prevention of thromboembolic events in antiphospholipid syndrome (APS), non-vitamin K antagonists oral anticoagulants/direct oral anticoagulants (DOACs) have been used off-label. Objective We aimed to perform a systematic review comparing DOACs to VKA regarding prevention of thromboembolic events, occurrence of bleeding events and mortality in patients with APS. Methods An electronic database search was performed through MEDLINE, CENTRAL and Web of Science. After data extraction, we pooled the results using risk ratio (RR) and 95% CI. Heterogeneity was assessed using the I². The outcomes considered were all thromboembolic events as primary, and major bleeding, all bleeding events and mortality as secondary. Evidence confidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results We included 7 studies and a total of 835 patients for analyses. Thromboembolic events were significantly increased in DOACs arm, compared with VKA—RR 1.69, 95% CI 1.09 to 2.62, I²—24%, n=719, 6 studies. In studies using exclusively rivaroxaban, which was the most representative drug in all included studies, the thromboembolic risk was increased threefold (RR 3.36, 95% CI 1.53 to 7.37). The risks of major bleeding, all bleeding events and mortality were not significantly different from control arm. The grade of certainty of our results is very low. Conclusions Current evidence suggests DOACs use, particularly rivaroxaban, among patients with APS, is less effective than VKA since it is associated with 69% increased risk of thromboembolic events. Trial registration number CRD42020216178.
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Affiliation(s)
- Nazariy Koval
- Universidade de Lisboa Faculdade de Medicina, Lisbon, Portugal
| | - Mariana Alves
- Laboratório de Farmacologia Clinica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Medicina III, Hospital Pulido Valente (CHULN), Lisboa, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Rui Plácido
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Lisboa, Portugal
| | - Ana G Almeida
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Lisboa, Portugal
| | - João Eurico Fonseca
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Serviço de Reumatologia, Centro Hospitalar Universitario Lisboa Norte (CHULN), Lisboa, Portugal
| | - Joaquim J Ferreira
- Laboratório de Farmacologia Clinica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,CNS - Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Fausto J Pinto
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Lisboa, Portugal
| | - Daniel Caldeira
- Laboratório de Farmacologia Clinica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal .,Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Lisboa, Portugal
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10
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Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545-e608. [PMID: 34352278 DOI: 10.1016/j.chest.2021.07.055] [Citation(s) in RCA: 328] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 01/06/2023] Open
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11
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Sayar Z, Nallamilli S, Efthymiou M, Lambert J, Cohen H. Coexistent antiphospholipid syndrome and myeloproliferative neoplasm. Lupus 2021; 30:1502-1508. [PMID: 34192956 DOI: 10.1177/09612033211021154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiphospholipid syndrome (APS) and myeloproliferative neoplasms (MPN) are associated with an increased risk of thrombosis. The optimal management of patients with coexistent APS and MPN has not been defined. A single centre and systematic literature review of patients with coexistent APS and MPN was performed. Cases were divided into two groups based on whether they met international consensus criteria for APS. Of the 12 studies identified, eight were excluded (leaving five of a total 54 patients), as although antiphospholipid antibodies (aPL) were documented, the diagnosis of APS was not conclusively demonstrated. Another ten patients with definite APS were identified at our centre. Fifteen patients (ten females, five males) were therefore included in this analysis (eleven definite APS and four highly likely), median age 44 (range: 13-71) years. Nine had polycythaemia vera and six, essential thrombocythaemia. Thirteen of the 15 patients (86.7%) had thrombotic APS (seven with initial venous events and six arterial) and two (13.3%) had obstetric APS. Nine patients were single-positive, and six double-positive for aPL. None were triple aPL-positive. Four patients at our centre had recurrent thrombotic/obstetric events, including while on anticoagulation/antiplatelet treatment.
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Affiliation(s)
- Zara Sayar
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Susanna Nallamilli
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK.,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.,Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jonathan Lambert
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK.,Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Roffé A, Guedon A, Lallmahomed E. [Actual use of direct oral anticoagulants in venous thromboembolic disease]. Rev Med Interne 2021; 43:82-88. [PMID: 34176700 DOI: 10.1016/j.revmed.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 12/29/2022]
Abstract
Direct oral anticoagulants recently became the first-line choice for anticoagulation in venous thromboembolic disease. Many studies have shown its non-inferiority regarding the risk of thromboembolic recurrence compared to anti-vitamin K without increasing the risk of bleeding in the general population. However, specific populations such as patients with cancer, patients with kidney failure, patients with constitutional thrombophilia, elderly patients, or patients with extreme weight are at risk of intolerance to the use of direct oral anticoagulants. Precautions in use may be necessary as discussed in recently published guidelines about antiphospholipid syndrome. This review aims to list the main clinical trials investigating direct oral anticoagulants in venous thromboembolic disease in the general population and populations at risk, as well as to provide an update on current international and French guidelines.
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Affiliation(s)
- A Roffé
- Service de médecine vasculaire, hôpital Européen Georges-Pompidou, Paris, France.
| | - A Guedon
- Service de médecine vasculaire, hôpital Européen Georges-Pompidou, Paris, France
| | - E Lallmahomed
- Service de cardiologie, Centre hospitalier intercommunal Robert-Ballanger, Aulnay-sous-Bois, France
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13
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Respiratory Manifestations in Systemic Lupus Erythematosus. Pharmaceuticals (Basel) 2021; 14:ph14030276. [PMID: 33803847 PMCID: PMC8003168 DOI: 10.3390/ph14030276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by a wide spectrum of clinical manifestations. The respiratory system can be involved in up to 50-70% of patients and be the presenting manifestation of the disease in 4-5% of cases. Every part of the respiratory part can be involved, and the severity can vary from mild self-limiting to life threatening forms. Respiratory involvement can be primary (caused by SLE itself) or secondary (e.g., infections or drug toxicity), acute or chronic. The course, treatment and prognosis vary greatly depending on the specific pattern of the disease. This review article aims at providing an overview of respiratory manifestations in SLE along with an update about therapeutic approaches including novel biologic therapies.
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14
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Pengo V, Hoxha A, Andreoli L, Tincani A, Silvestri E, Prisco D, Fierro T, Gresele P, Cafolla A, De Micheli V, Ghirarduzzi A, Tosetto A, Falanga A, Martinelli I, Testa S, Barcellona D, Gerosa M, Denas G. Trial of Rivaroxaban in AntiPhospholipid Syndrome (TRAPS): Two-year outcomes after the study closure. J Thromb Haemost 2021; 19:531-535. [PMID: 33128325 DOI: 10.1111/jth.15158] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/04/2020] [Accepted: 10/26/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Trial of Rivaroxaban in AntiPhospholipid Syndrome was a prospective randomized, open-label, noninferiority study conducted in 14 centers in Italy. Rivaroxaban was compared with warfarin for the prevention of thromboembolic events, major bleeding, and vascular death in high-risk, triple-positive patients with antiphospholipid syndrome. OBJECTIVE The aim of this paper is to report the events during the 2-year follow-up after the study closure. METHODS On January 28, 2018, the trial was prematurely stopped by adjudication and safety committee for an excess of events in the rivaroxaban group. Randomized patients were advised on trial results and those randomized to rivaroxaban were solicited to switch to warfarin. All 14 participating centers were asked and accepted to follow their patients for clinical events. This report describes the rate of events that occurred between January 28, 2018, and January 28, 2020. RESULTS Of 120 randomized patients, 115 were available for follow-up. Outcome events were two in six (33.3%) patients who remained on direct oral anticoagulants (DOACs) and six in 109 (5.7%) patients on warfarin (hazard ratio [HR] 6.9; 95% confidence interval [CI] 1.4-34.5, P = .018). The two patients on DOACs (one taking dabigatran and one taking rivaroxaban) suffered from thromboembolic events, whereas of the six patients with composite outcomes on warfarin, three had thromboembolic events (HR for thrombosis 13.3; 95% CI 2.2-79.9, P = .005). CONCLUSION These data further support the use of warfarin in high-risk patients with antiphospholipid syndrome.
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Affiliation(s)
- Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardiac Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Ariela Hoxha
- Internal Medicine, San Bortolo Hospital, Vicenza, Italy
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology ASST-Spedali Civili di Brescia, Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology ASST-Spedali Civili di Brescia, Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Tiziana Fierro
- Section of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
| | - Paolo Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
| | - Arturo Cafolla
- Department of Translational and Precision Medicine and Hematology, Sapienza University of Rome, Rome, Italy
| | | | - Angelo Ghirarduzzi
- Angiology Unit, Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy
| | | | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine and Hemostasis and Thrombosis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Sophie Testa
- Hemostasis and Thrombosis Center, Laboratory Medicine Department, Azienda Socio-Sanitaria Territoriale, Cremona, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Maria Gerosa
- Clincal Rheumatology Unit, Research Center for Adult and Pediatric Diseases, Department of Clinical Sciences and Community Health, ASST Pini-CTO, University of Milan, Milan, Italy
| | - Gentian Denas
- Thrombosis Research Laboratory, Department of Cardiac Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova, Italy
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15
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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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16
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Wadsworth D, Sullivan E, Jacky T, Sprague T, Feinman H, Kim J. A review of indications and comorbidities in which warfarin may be the preferred oral anticoagulant. J Clin Pharm Ther 2021; 46:560-570. [PMID: 33393699 DOI: 10.1111/jcpt.13343] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs. METHODS We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions. RESULTS AND DISCUSSION Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent. WHAT IS NEW AND CONCLUSION New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.
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Affiliation(s)
- Daniel Wadsworth
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Emma Sullivan
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Thomas Jacky
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Taylor Sprague
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Hannah Feinman
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jennifer Kim
- Cone Health Department of Internal Medicine, Greensboro, NC, USA
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17
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Management of Antiphospholipid Syndrome. Biomedicines 2020; 8:biomedicines8110508. [PMID: 33212808 PMCID: PMC7696303 DOI: 10.3390/biomedicines8110508] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/09/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023] Open
Abstract
Antiphospholipid syndrome (APS), is an acquired autoimmune disorder characterised by thrombosis, pregnancy morbidity, and the presence of antiphospholipid antibodies (aPL). Although venous thromboembolism is the most common manifestation, thrombotic events in APS may also occur in virtually any vascular bed, with cerebral circulation being the arterial territory most commonly affected. As APS is a heterogeneous condition, its management should be tailored with a patient-centred approach based on individual risk assessment, which includes the aPL profile, concomitant auto-immune diseases, and traditional cardiovascular risk factors. Although literature data are conflicting regarding primary prophylaxis, there is some evidence indicating that antiplatelet agents may reduce the risk of a first thrombotic event in individuals with a high-risk profile. In patients with thrombotic APS, current evidence-based guidelines recommend lifelong vitamin K antagonists (VKAs), preferably warfarin. The optimal intensity of anticoagulation following arterial thrombosis remains controversial. Arterial thrombosis should be treated either with high-intensity warfarin at a target INR > 3.0, or low-dose aspirin (LDA) combined with moderate-intensity warfarin (INR 2.0-3.0). It is recommended to avoid direct oral anticoagulants (DOACs) in patients with high-risk APS, mainly those with triple-positive PL and previous arterial events. They would only be used exceptionally in selected patients with low-risk venous thromboembolism (VTE). In low-risk VTE patients currently treated with a DOAC due to warfarin intolerance or a previous unstable International Normalized Ratio on warfarin, the decision of continuing DOACs would be taken in carefully selected patients. In women with obstetric APS, the combination therapy with LDA plus heparin remains the conventional strategy.
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18
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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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19
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Zuily S, Cohen H, Isenberg D, Woller SC, Crowther M, Dufrost V, Wahl D, Doré CJ, Cuker A, Carrier M, Pengo V, Devreese KMJ. Use of direct oral anticoagulants in patients with thrombotic antiphospholipid syndrome: Guidance from the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2020; 18:2126-2137. [PMID: 32881337 DOI: 10.1111/jth.14935] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/20/2020] [Accepted: 05/18/2020] [Indexed: 01/17/2023]
Abstract
Clarity and guidance is required with regard to the use of direct oral anticoagulants in antiphospholipid syndrome (APS) patients, within the confines of the recent European Medicines Agency recommendations, discrepant recommendations in other international guidelines and the limited evidence base. To address this, the Lupus Anticoagulant/Antiphospholipid Antibodies Scientific and Standardization Committee (SSC) chair and co-chairs together with SSC Control of Anticoagulation members propose guidance for healthcare professionals to help them manage APS patients. Uncertainty in this field will be addressed. This guidance will also serve as a call and focus for research.
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Affiliation(s)
- Stéphane Zuily
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - 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
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, UT, USA
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginie Dufrost
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - Denis Wahl
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
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20
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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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21
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Booth S, Burton K, Hunt B, Desborough M. Antiphospholipid syndrome and challenges with direct oral anticoagulants. Br J Hosp Med (Lond) 2020; 81:1-11. [PMID: 32468937 DOI: 10.12968/hmed.2020.0080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Direct oral anticoagulants have become the mainstay of the management of venous thromboembolism and atrial fibrillation, and long-term anticoagulation is indicated for those at high risk of further thrombotic events. This includes patients diagnosed with antiphospholipid syndrome, for whom the 'triple positive' laboratory combination of lupus anticoagulant, β2-glycoprotein-1 and anti-cardiolipin antibodies signify those at greatest risk. Data from meta-analysis and randomised control trials have raised the concern that direct oral anticoagulants may be less effective than vitamin K antagonists for the prevention of thrombosis in patients with thrombotic antiphospholipid syndrome, particularly those with the triple positive profile. This article reviews the diagnosis of thrombotic antiphospholipid syndrome, strategies for testing without interruption of anticoagulation, evidence concerning the safety of direct oral anticoagulants in this setting, and the implications for current investigation and management of unprovoked venous thromboembolism.
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Affiliation(s)
- Stephen Booth
- Department of Oncology, University of Oxford, Oxford, UK
| | - Kieran Burton
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Beverley Hunt
- Haemophilia and Thrombosis Centre, St Thomas' Hospital, London, UK
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22
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Cohen H, Efthymiou M, Isenberg DA. Use of direct oral anticoagulants in antiphospholipid syndrome: Reply. J Thromb Haemost 2020; 18:259-261. [PMID: 31894665 DOI: 10.1111/jth.14674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 10/31/2019] [Indexed: 01/12/2023]
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
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - David A Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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