Factor V Leiden and prothrombin gene mutation in inflammatory bowel disease in a Mediterranean area

Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review

Patients with inflammatory bowel disease (IBD), both Crohn's disease and ulcerative colitis, frequently experience venous thromboembolism (VTE), a potentially fatal consequence. The pathophysiological mechanisms contributing to VTE include inflammation, modifications in coagulation factors, endothelial dysfunction, and platelet activation. Numerous pro-inflammatory cytokines and markers, such as tumor necrosis factor-alpha and interleukin-6, have a significant impact on the thrombotic cascade. Patients with IBD are more likely to suffer VTE for a variety of causes. Exacerbations of preexisting conditions, admission to the hospital, surgical intervention, immobilization, corticosteroid usage, central venous catheterization, and hereditary susceptibility all fit into this category. The mainstay of therapy for VTE in IBD patients includes anticoagulation that is individualized for each patient depending on the thrombosis site, severity, bleeding risk, and interaction with other drugs. In some high-risk IBD patients, such as those having major surgery or hospitalized with severe flare, preventive anticoagulation may play a role. However, the acceptance rate for this recommendation is low. Additionally, there is a subset of patients who would require extended thromboprophylaxis. The majority of the studies that looked into this question consisted of patients in the surgical setting. Emerging data suggest that risk factors other than surgery can also dictate the duration of anticoagulation. While extending anticoagulation in all patients may help reduce VTE-related mortality, identifying these risk factors is important. Hence, the decision to initiate prophylaxis should be individualized, considering the overall thrombotic and bleeding risks. This review explores the relationship between IBD and VTE, including risk factors, epidemiology, and prevention. A multifactorial approach involving aggressive management of underlying inflammation, identification of modifiable risk factors, and judicious use of anticoagulant therapy is essential for reducing the burden of VTE in this vulnerable population.

How to cite this article

Harindranath S, Varghese J, Afzalpurkar S, et al. Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review. Euroasian J Hepato-Gastroenterol 2023;13(2):133-141.

Shedding Light on Hemostasis in Patients With Inflammatory Bowel Diseases

Patients with inflammatory bowel diseases (IBD) have an increased risk of thrombosis, possibly due to changes in blood cells and molecules involved in hemostasis. They have increased platelet counts and reactivity as well as increased platelet-derived large extracellular vesicles. Coagulation is continuously activated in patients with IBD, based on measured markers of thrombin generation, and the anticoagulant functions of endothelial cells are damaged. Furthermore, fibrinogen is increased and fibrin clots are denser. However, pathogenesis of thrombosis in patients with IBD appears to differ from that of patients without IBD. Patients with IBD also take drugs that might contribute to risk of thrombosis, complicating the picture. We review the features of homeostasis that are altered in patients with IBD and possible mechanisms of this relationship.

Antiphospholipid Antibodies and Procoagulant Profile in Tunisians With Inflammatory Bowel Diseases

The hypercoagulable state accompanying inflammatory bowel diseases (IBDs) is still poorly understood. The aim of this study was to assess antiphospholipid antibodies (APAs) and a large panel of inherited and acquired thrombotic markers simultaneously in a sample of Tunisian patients with IBD. In total, 89 consecutive patients with IBD (mean age 38 ± 15 years; 48 with Crohn disease and 41 with ulcerative colitis) and 129 controls were prospectively evaluated for immunoglobulin (Ig) G, IgM, and IgA antibodies against cardiolipin (aCL), β2glycoprotein I (aβ2GPI), and prothrombin (aPT); IgG and IgM antibodies against phosphatidic acid (aPA), phosphatidylinositol (aPI), and annexin V (aAnnV); lupus anticoagulant (LA); coagulation factors; natural inhibitors; and thrombotic genetic polymorphisms. Levels of fibrinogen, factors II, V, and VIII and von Willebrand factor, antithrombin, and protein C were significantly higher in patients with IBD than in controls (P < .05 for all comparisons). At least 1 APA subset was detected in 54 patients. The frequencies of antibodies against anionic phospholipids-aCL, aPI, and aPA-in patients with IBD were 15.9%, 21.3%, and 14.6%, respectively. The frequencies of antiphospholipid cofactor antibodies were 39.8% for aβ2GPI and 15.7% for both aAnnV and aPT. Isolated aβ2GPI IgA was detected in 22 patients, and 12 (13.5%) patients had LA. The IgA aβ2GPI antibodies were frequently detected in Tunisian patients with IBD. These results are of potential diagnostic, prognostic, and therapeutic interest.

Increased risk of venous thromboembolic events with corticosteroid vs biologic therapy for inflammatory bowel disease

BACKGROUND & AIMS

We investigated whether treatment of active inflammatory bowel disease with biologic agents is associated with a reduced risk of venous thromboembolic events (VTEs) compared with corticosteroid therapy.

METHODS

We performed a retrospective analysis of 15,100 adults with inflammatory bowel disease who were identified from the Truven Health MarketScan databases. We analyzed data from patients who received 6 months of continuous medical and prescription coverage before and 12 months after their first diagnosis and had no VTE during the 6 months before they first received biologic or corticosteroid therapy. The outcome assessed was any VTE that occurred during the 12-month follow-up period. A multivariate logistic regression model was used to evaluate the effects of biologic, corticosteroid, and combination therapies (biologics and corticosteroids) on VTE risk.

RESULTS

Three hundred twenty-five VTEs occurred during the study period (in 2.25% of patients receiving only corticosteroids, in 0.44% of patients receiving biologics, and in 2.49% of patients receiving combination therapy). Compared with patients receiving only corticosteroids, the odds ratio for VTE in patients receiving only biologics was 0.21 (95% confidence interval, 0.05-0.87) in the multivariate model, and the odds ratio for VTE in patients on combination therapy was 1.01.

CONCLUSIONS

Compared with treatment with only a biologic agent, corticosteroid therapy is associated with a nearly 5-fold increase in risk for VTE. Combination therapy with corticosteroids and biologic agents was associated with the same risk for VTE as that of corticosteroids alone. Corticosteroids therefore appear to increase risk for VTE.

Are inherited thrombotic risk factors associated with fibrostenosis in Crohn's disease?

BACKGROUND

Fibrostenotic lesions are common complications in Crohn's disease (CD) often requiring surgery. Inherited thrombotic risk factors are associated with fibrosis in other chronic inflammatory diseases. The aim of the study was to assess whether inherited thrombotic risk factors are associated with fibrostenosis in CD.

METHODS

Clinical data on 529 CD patients were collected retrospectively. Subjects were tested for and grouped according to the presence of factor V Leiden (FVL), the prothrombin G20210A, and the methylenetetrahydrofolate reductase C677T mutation (MTHFR). Patients who underwent CD-related intestinal surgery were assessed for the presence of fibrostenosis, which was the primary endpoint. The diagnosis of fibrostenosis was based on surgical, pathological, and histopathological reports. A Cox proportional hazards model was used for statistical analysis.

RESULTS

Thirty-two (6.1%, heterozygous 30, homozygous 2) patients were carriers of FVL, 19 (3.6%, all heterozygous) carried the prothrombin variant, and 318 (60.1%) the MTHFR variant (243 heterozygous, 75 homozygous). In all, 303 (57.3%) patients underwent intestinal surgery. Fibrostenosis was identified in 219 (72.3%) surgical specimens. The rate of first intestinal surgeries with fibrostenosis tended to be more frequent in patients with the homozygous 677TT MTHFR mutation (hazard ratio, HR 1.39; 95% confidence interval [CI]: 0.98-1.97; P = 0.067). After adjustment for potential confounders homozygous 677TT MTHFR mutation did not remain a risk factor for intestinal surgery with fibrostenosis (HR 1.23; 95% CI: 0.77-1.98; P = 0.387). FVL and the prothrombin variant had no influence on the primary endpoint.

CONCLUSIONS

The MTHFR 677TT mutation, factor V Leiden, and the prothrombin G20210A mutation are not associated with fibrostenosis in CD.

Factor V Leiden and inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Recent studies proved that inflammatory bowel disease (IBD) patients had a higher risk of thromboembolism and a Factor V Leiden mutation that prevents the efficient inactivation of factor V, which leads to thromboembolism and thus contributes to a high potential risk of IBD. However, the relationship between Factor V Leiden mutation and IBD remains controversial.

METHODS

We conducted a systematic review with meta-analysis of studies assessing the association of Factor V Leiden mutation with the risk of IBD in humans. We extracted the number of IBD and control subjects with or without Factor V Leiden mutation from each study and conducted this analysis using a fixed-effects model.

RESULTS

Nineteen studies met the inclusion criteria and were included in the meta-analysis. No significant heterogeneity was found in results across the 19 studies (I (2) = 18.8%, P = 0.23), which showed a slight but not significant increase in the risk of IBD with Factor V Leiden mutation in the general population (summary odds ratio [OR] 1.13, 95% confidence interval [CI] 0.87-1.46). Taking into account ethnic differences, further study exhibited a slight but not significant increase in risk of IBD with Factor V Leiden mutation in Europeans (summary OR 1.20, 95% CI 0.88-1.64). However, Factor V Leiden mutation was significantly associated with a higher risk of thromboembolism in IBD patients (summary OR 5.30, 95% CI 2.25-12.48). No publication bias was found in this study.

CONCLUSIONS

This meta-analysis indicated that although Factor V Leiden mutation was not significantly associated with the risk of IBD, it was significantly associated with a higher risk of thromboembolism in IBD patients.

Factor V Leiden and thrombosis in patients with inflammatory bowel disease (IBD): a meta-analysis

BACKGROUND

Testing for genetic risks of Factor V Leiden ( FVL ) in inflammatory bowel disease (IBD) patients with thromboembolism (TE) is common, but the safety and utility of such testing need review.

AIM

The aim of the present study was to investigate whether the FVL polymorphisms would be one inherited prothrombotic risk factor that could significantly increase the risk of thrombosis in patients with IBD.

METHODS

We performed an electronic databases search to identify published studies correlating the FVL mutations with four populations including one IBD group with TE complications, one control IBD group without TE complications, one control non-IBD group with TE complications and another healthy control (HC) group. Statistical analysis was performed with Review Manager (RevMan) 5.0. Sub-analysis/sensitivity analysis was also performed.

RESULTS

We identified 112 titles and included 22 studies in this meta-analysis. The odds ratio (OR) of TE in IBD patients with FVL was higher as compared with IBD patients (OR: 4.00; 95%CI: 2.04, 7.87) and HC (OR: 3.19; 95%CI: 1.38, 7.36). There was a 1.25-fold (95%CI: 0.90-1.74) increase in incidence of FVL gene mutation in IBD patients compared with HC. The FVL mutations were not significantly different between IBD patients with thrombosis and non-IBD patients with thrombosis (OR: 0.79; 95%CI: 0.43, 1.47).

CONCLUSION

FVL plays a role in IBD-TE, but to no greater extent than it does in the general population with TE.

Haemostatic system in inflammatory bowel diseases: New players in gut inflammation

Inflammation and coagulation constantly influence each other and are constantly in balance. Emerging evidence supports this statement in acute inflammatory diseases, such as sepsis, but it also seems to be very important in chronic inflammatory settings, such as inflammatory bowel disease (IBD). Patients with Crohn’s disease and ulcerative colitis have an increased risk of thromboembolic events, and several abnormalities concerning coagulation components occur in the endothelial cells of intestinal vessels, where most severe inflammatory abnormalities occur. The aims of this review are to update and classify the type of coagulation system abnormalities in IBD, and analyze the strict and delicate balance between coagulation and inflammation at the mucosal level. Recent studies on possible therapeutic applications arising from investigations on coagulation abnormalities associated with IBD pathogenesis will also be briefly presented and critically reviewed.

Thrombosis and inflammatory bowel disease-the role of genetic risk factors

Thromboembolism is a significant cause of morbidity and mortality in patients with inflammatory bowel disease (IBD). Recent data suggest thromboembolism as a disease-specific extraintestinal manifestation of IBD, which is developed as the result of multiple interactions between acquired and genetic risk factors. There is evidence indicating an imbalance of procoagulant, anticoagulant and fibrinolytic factors predisposing in thrombosis in patients with IBD. The genetic factors that have been suggested to interfere in the thrombotic manifestations of IBD include factor V Leiden, factor II (prothrombin, G20210A), methylenetetrahydrofolate reductase gene mutation (MTHFR, 6777T), plasminogen activator inhibitor type 1 (PAI-1) gene mutation and factor XIII (val34leu). In this article we review the current data and future prospects on the role of genetic risk factors in the development of thromboembolism in IBD.

Mutations in clotting factors and inflammatory bowel disease

BACKGROUND

Patients with Crohn's disease (CD) and ulcerative colitis (UC) have a three- to fourfold greater risk of venous thrombosis compared with the general population. We aimed to determine if patients with CD and UC had a greater likelihood of mutations in genes that increase clotting risk, in a population-based case-control study.

METHODS

Subjects were drawn from the University of Manitoba IBD Research Registry and controls were drawn from Manitoba Health's administrative database. Cases (CD, N = 327; UC, N = 165) and controls (N = 412) underwent venipuncture. DNA was purified from whole blood. Genotypes for wild-type and common mutations that have been associated with venous thrombosis for each of Factor II (prothrombin) (G20210A), Factor V (G1691A:'Leiden'), methylenetetrahydrofolate reductase (MTHFR, C677T), and Factor XIII (val34leu) were assessed.

RESULTS

A total of 1.5% and 6.1% were heterozygous for Factor II and Factor V variants, respectively, without differences among cases and controls. Only one subject was homozygous for Factor V Leiden (and none were homozygous for Factor II mutation). Although some differences were observed among cases and controls in the prevalence of MTHFR C677T (decrease in mutant allele carriership in UC) and FXIII val34leu (increase in double mutant allele carriership in CD), these did not explain an excess risk of thrombosis. Age, sex, or disease phenotypes were not associated with prothrombotic genotypes.

CONCLUSIONS

While there was a slightly greater prevalence of Factor XIII mutation carriership in CD, we did not find that gene mutations for these four common factors could explain the greater risk of venous thrombosis in CD and UC.

Inflammation and coagulation in inflammatory bowel disease: The clot thickens

Inflammation and coagulation play crucial roles in the pathogenesis of multiple chronic inflammatory disorders. Growing evidence highlights a tight mutual network in which inflammation, coagulation, and fibrinolysis play closely related roles. Crohn's disease (CD) and ulcerative colitis (UC), the two major forms of inflammatory bowel disease (IBD), are chronic inflammatory conditions, characterized by a hypercoagulable state and prothrombotic conditions, and accompanied by abnormalities in coagulation. From a pathophysiological point of view, cells and molecules classically implicated in the physiological process of coagulation have now been shown to behave abnormally in IBD and possibly to also play an active role in disease pathogenesis and/or disease progression. This paper reviews studies performed on the coagulation profile and risk factors for thrombosis in IBD. In particular, an overview is provided of the epidemiology, clinical features, and etiology of thromboembolic complications in IBD. Furthermore, we review hemostatic abnormalities in IBD, as well as the cell types involved in such processes. Finally, we highlight the coagulation system as a dynamic participant in the multifaceted process of chronic intestinal inflammation. Overall, an overview is provided that the coagulation system represents an important, though previously underestimated, component of IBD pathogenesis, and may be a possible target for therapeutic intervention.

What is the impact of resistance to activated protein C (Leiden mutation to factor V) in inflammatory bowel disease?

BACKGROUND AND AIMS

Resistance to activated protein C (APCR) caused by the Leiden mutation to factor V is the most common cause of inherited thrombosis. Patients with inflammatory bowel disease (IBD) are considered to have an increased risk of thromboembolic complications, and the role of APCR as a cause has previously been investigated. In this study, we investigated if APCR was associated with non-thrombotic morbidities in IBD.

PATIENTS/METHODS

Of 951 patients asked to participate, 389 agreed by returning a signed informed consent and filled questionnaire and took the blood test for APCR. Self-reported IBD-related surgery was used as a rough indicator for increased morbidity.

RESULTS

APCR was present in 6.6% of patients with Crohn's disease (CD; 10/152) and in 12.7% of ulcerative colitis (UC) patients (30/237). The difference of 6.1% is significant (p=0.039). Among patients with CD and APCR, 9 out of 10 had had surgery, significantly more than among those without APCR (81/142). In patients with UC and APCR, 10 out of 30 had had surgery, still significantly more than in those without APCR (36/207). For the whole group of IBD patients, APCR is associated with a significantly increased risk for thrombosis (p=0.0018), and for the UC group (8/28) p=0.0029, but not for the CD patients alone (2/9), p=0.2323. No other significant differences could be shown for parameters normally related to increased morbidity.

CONCLUSIONS

APCR in IBD was associated with an increased frequency of IBD-related surgery, which may warrant screening for APCR in therapy-resistant IBD. In patients with APCR, it may be more difficult and/or important to control inflammation.

Prothrombin G20210A mutation in cases with recurrent miscarriage: a study of the mediterranean population

BACKGROUND

Thrombophilic predisposition may be one of the underlying causes of recurrent miscariage (RM). The purpose of this study was to evaluate the Prothrombin G20210A mutation in cases with history of RM.

MATERIAL AND METHODS

A total of 104 cases, 55 with diagnosis of RM and 49 control cases, were included in this controlled study. In all cases, in addition to full examination tests, Prothrombin 20210A mutation analysis was carried out by means of Polymerase Chain Reaction (PCR).

RESULTS

Mean number of the abortion was 3.51 +/- 0.74 in the RM group and 0.08 +/- 0.27 in the control group (p < 0.05). As a consequence of comprehensive examinations, in 24 (43.6%) of 55 RM cases at least one etiologic factor was put forth. Prothrombin G20210A mutation was observed in six (10.9%) cases of the RM group and one (2.04%) in the control group (p < 0.05). Four of the six cases (66.7%) of Prothrombin G20210A mutation had a subsequent pregnancy. Among these four pregnancies, there was one spontaneous loss at 14 weeks of gestation and one severe pre-eclampsia.

CONCLUSION

Our data together with literature suggest that Prothrombin G20210A mutation may be associated with RM. We recommend this genetic testing as a screening tool for women with history of RM.

Thrombosis in inflammatory bowel diseases: role of inherited thrombophilia

BACKGROUND

Inflammatory bowel diseases (IBD) are characterized by an increased risk for venous and arterial thrombosis. Although the pathogenetic mechanisms of this predisposition are unclear, a possible role of inherited risk factors for thrombosis in determining this predisposition has been suggested.

AIM

To evaluate the role of factor V Leiden (G1691A) and G20210A prothrombin gene mutations in determining the occurrence of thrombosis in IBD patients.

PATIENTS AND METHODS

Forty-seven IBD patients (30 ulcerative colitis and 17 Crohn's disease) with a positive history for thrombosis (9 at arterial sites and 38 at venous sites) were enrolled in the study. For each patient, two non-IBD subjects matched for sex and age, type, and site of thrombosis were used as controls. Peripheral blood DNA specimens were amplified by PCR using appropriate primers and analyzed by restriction analysis on agarose gel electrophoresis. Statistical analysis was performed by means of Fisher's exact test.

RESULTS

The total number of subjects with one or both mutations was significantly lower in IBD patients with thrombosis than in control subjects (12.8%vs 29.8%, respectively; p= 0.035, OR = 0.34, 95% CI 0.13-0.90). The total frequency of the mutated alleles was also significantly lower in IBD than in controls (7.4%vs 16.5%, respectively; p= 0.041, OR = 0.40, 95% CI 0.17-0.96). Prothrombotic mutations were particularly unfrequent in IBD patients with active disease at the time of thrombosis compared with patients with quiescent disease (8.0%vs 36.4%, respectively; p= 0.057, OR = 0.15, 95% CI 0.02-1.01).

CONCLUSIONS

The major inherited risk factors for thrombosis are significantly less frequent in thrombotic IBD patients than in thrombotic non-IBD subjects, suggesting that acquired risk factors play the most relevant role in determining thromboembolic events observed in IBD patients, particularly during active phases of the disease.

Intracranial sinus thrombosis in a patient with Crohn disease and factor V Leiden mutation

There is a well-known risk of thrombosis in patients with inflammatory bowel disease. Documented cases of intracranial sinus thrombosis in this setting are rare. We present the case of a 30-year-old man with Crohn disease who spontaneously developed a superior sagittal sinus thrombosis and bifrontal infarcts that resulted in death. The patient was heterozygous for factor V Leiden mutation. The literature was searched to assess the frequency of cerebral venous infarcts in inflammatory bowel disease and the role that factor V Leiden plays in thrombosis in such patients.

Review article: inherited thrombophilia in inflammatory bowel disease

Individuals with inflammatory bowel disease frequently experience increased systemic thromboembolic complications, which represent an important cause of morbidity and mortality. Risk factors for thrombosis can be inherited or acquired. The most common inherited risk factors for thromboembolism are factor V Leiden mutation, G20210A mutation in the prothrombin gene, and homozygous C677T mutation in the methylenetetrahydrofolate reductase gene. In the last few years, a great amount of literature has focused on the prevalence of such genetic mutations and their role in determining thrombosis in IBD patients. In this review, we summarize the results of these studies.

Val34Leu factor XIII polymorphism in Italian patients with inflammatory bowel disease

BACKGROUND

Coagulation Factor XIII is implicated in fibrin stabilization and wound healing. Plasma levels of Factor XIII are reduced in inflammatory bowel disease patients; recently, a valine 34 to leucine polymorphism of the Factor XIII-A subunit gene with a defined protective effect against thrombosis and as yet undetermined effect on wound healing has been described.

AIM

To evaluate Val34Leu Factor XIII polymorphism distribution and to find possible correlations with clinical features in Italian inflammatory bowel disease patients.

STUDY POPULATION

A total of 152 inflammatory bowel disease patients, 90 with ulcerative colitis and 62 with Crohn's disease and 130 healthy volunteers were studied.

METHODS

Val34Leu polymorphism was detected by RFLP with BsaH I. Statistical analysis was performed by means of Fisher exact test.

RESULTS

In inflammatory bowel disease, 57.2% of patients showed the wild type status, 37.5% were heterozygous and 5.3% were homozygous for the 34Leu allele; the frequency of the mutated allele was 24.0%. In controls, 66.1% of subjects showed the wild type status, 28.5% were heterozygous and 5.4% were homozygous for the 34Leu allele; the frequency of the mutated allele was 19.7%. There was no difference in genotype distribution and prevalence of the mutated allele between inflammatory bowel disease patients and controls.

CONCLUSIONS

The present data do not show any differences in Val34Leu Factor XIII polymorphism distribution between inflammatory bowel disease patients and controls. The prothrombotic state described in inflammatory bowel disease patients does not depend on an altered distribution of Val34Leu Factor XIII polymorphism.