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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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2
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Feng W, Qiao J, Tan Y, Liu Q, Wang Q, Yang B, Yang S, Cui L. Interaction of antiphospholipid antibodies with endothelial cells in antiphospholipid syndrome. Front Immunol 2024; 15:1361519. [PMID: 39044818 PMCID: PMC11263079 DOI: 10.3389/fimmu.2024.1361519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 06/19/2024] [Indexed: 07/25/2024] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease with arteriovenous thrombosis and recurrent miscarriages as the main clinical manifestations. Due to the complexity of its mechanisms and the diversity of its manifestations, its diagnosis and treatment remain challenging issues. Antiphospholipid antibodies (aPL) not only serve as crucial "biomarkers" in diagnosing APS but also act as the "culprits" of the disease. Endothelial cells (ECs), as one of the core target cells of aPL, bridge the gap between the molecular level of these antibodies and the tissue and organ level of pathological changes. A more in-depth exploration of the relationship between ECs and the pathogenesis of APS holds the potential for significant advancements in the precise diagnosis, classification, and therapy of APS. Many researchers have highlighted the vital involvement of ECs in APS and the underlying mechanisms governing their functionality. Through extensive in vitro and in vivo experiments, they have identified multiple aPL receptors on the EC membrane and various intracellular pathways. This article furnishes a comprehensive overview and summary of these receptors and signaling pathways, offering prospective targets for APS therapy.
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Affiliation(s)
- Weimin Feng
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
- Institute of Medical Technology, Health Science Centre, Peking University, Beijing, China
| | - Jiao Qiao
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
- Institute of Medical Technology, Health Science Centre, Peking University, Beijing, China
| | - Yuan Tan
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
- Institute of Medical Technology, Health Science Centre, Peking University, Beijing, China
| | - Qi Liu
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
- Institute of Medical Technology, Health Science Centre, Peking University, Beijing, China
| | - Qingchen Wang
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
| | - Boxin Yang
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
| | - Shuo Yang
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
| | - Liyan Cui
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
- Institute of Medical Technology, Health Science Centre, Peking University, Beijing, China
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Erkan D. Expert Perspective: Management of Microvascular and Catastrophic Antiphospholipid Syndrome. Arthritis Rheumatol 2021; 73:1780-1790. [PMID: 34114366 DOI: 10.1002/art.41891] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Doruk Erkan
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
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4
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Mormile I, Granata F, Punziano A, de Paulis A, Rossi FW. Immunosuppressive Treatment in Antiphospholipid Syndrome: Is It Worth It? Biomedicines 2021; 9:biomedicines9020132. [PMID: 33535377 PMCID: PMC7911562 DOI: 10.3390/biomedicines9020132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/18/2021] [Accepted: 01/26/2021] [Indexed: 11/16/2022] Open
Abstract
The antiphospholipid syndrome (APS) is characterized by the development of venous and/or arterial thrombosis and pregnancy morbidity in patients with persistent antiphospholipid antibodies (aPL). Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening form of APS occurring in about 1% of cases. Lifelong anticoagulation with vitamin K antagonists remains the cornerstone of the therapy for thrombotic APS, but frequently the use of anticoagulation may be problematic due to the increased risk of bleeding, drug interactions, or comorbidities. Immunosuppressant drugs are widely used to treat several autoimmune conditions, in which their safety and effectiveness have been largely demonstrated. Similar evidence in the treatment of primary APS is limited to case reports or case series, and studies on a large scale lack. Immunomodulatory drugs may be an emerging tool in managing such particular situations, like refractory obstetrical complications, CAPS, or so-called APS non-criteria manifestations. In addition, immunomodulatory drugs may be useful in patients experiencing recurrent thromboembolic events despite optimized anticoagulant therapy. We did a comprehensive review of literature analyzing the possible role of immunomodulation in primary APS to provide a broad overview of potentially safe and effective target treatments for managing this devastating disease.
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Affiliation(s)
- Ilaria Mormile
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
| | - Francescopaolo Granata
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
| | - Alessandra Punziano
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
| | - Amato de Paulis
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, 80131 Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.G.); (A.P.); (A.d.P.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-81-7464513
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Polytarchou K, Varvarousis D, Manolis AS. Cardiovascular Disease in Antiphospholipid Syndrome. Curr Vasc Pharmacol 2020; 18:538-548. [DOI: 10.2174/1570161117666190830101341] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/18/2019] [Accepted: 08/18/2019] [Indexed: 12/13/2022]
Abstract
:
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by venous,
arterial or microvascular thrombosis or obstetric events in the presence of persistently positive
antiphospholipid antibodies and constitutes a major cause of cardiovascular events in young people.
Τhis review highlights the pathophysiology of cardiovascular complications in patients with APS and
possible treatment options.
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Patients with APS have endothelial dysfunction, accelerated endothelial proliferation and intimal hyperplasia,
atherogenesis, platelet activation, inflammatory products secretion and coagulation-fibrinolytic
dysregulation. Cardiovascular complications include accelerated atherosclerosis, acute coronary syndrome,
Libman-Sacks endocarditis, cardiomyopathy and venous, arterial or intracardiac thrombi.
Moreover, pulmonary hypertension and peripheral microvascular dysfunction are common findings.
:
Management of these patients is not well documented. The role of primary thrombosis prevention remains
controversial in individuals with positive antiphospholipid antibodies. Treatment of traditional
cardiovascular risk factors according to current guidelines for the prevention of cardiovascular disease
in the general population is recommended for primary prevention of APS. Anticoagulation therapy with
unfractionated or low-molecular-weight heparin overlapped with a vitamin K antagonist remains the
mainstay of the treatment for APS patients with venous thrombosis, whereas direct oral anticoagulants
are not yet recommended. Data are scarce regarding the secondary arterial thrombosis prevention and it
is not clear whether dual or triple antithrombotic therapy is necessary. To date, it is recommended to
follow current guidelines for the management of acute coronary syndrome in the general population.
New treatment targets are promising options for patients with catastrophic APS.
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Affiliation(s)
- Kali Polytarchou
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Dimitrios Varvarousis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Antonis S. Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
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van den Hoogen LL, van Laar JM. Targeted therapies in systemic sclerosis, myositis, antiphospholipid syndrome, and Sjögren's syndrome. Best Pract Res Clin Rheumatol 2020; 34:101485. [PMID: 32067925 DOI: 10.1016/j.berh.2020.101485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Targeted therapies using biological disease-modifying antirheumatic drugs (bDMARDs) and small molecule synthetic drugs have revolutionized rheumatological practice. Initially developed for the treatment of immune arthritis (rheumatoid arthritis, psoriatic arthritis, and spondylarthritis), both bDMARDs and small molecule synthetic drugs are now increasingly entering the space of connective tissue disease (CTD) treatment. Recent clinical trial data in systemic sclerosis (SSc) have been particularly encouraging with positive effects on outcomes having been observed with nintedanib preventing the decline of lung function in patients with SSc-related interstitial lung disease. Randomized trials targeting B-cells by rituximab in primary Sjogren's syndrome have led to mixed results. Novel strategies to target B-cells in primary Sjögren's syndrome including ianalumab and belimumab are underway and will hopefully result in clear treatment effects. Inflammatory idiopathic myositis (polymyositis (PM) and dermatomyositis (DM)) and antiphospholid syndrome are proving to be more difficult to tackle but are nonetheless the subject of ongoing studies. To what extent new compounds can replace more traditional immunosuppressive drugs remains to be determined, but if the experience in immune arthritis has taught us anything it is that combination therapy may be the way to go.
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Affiliation(s)
- Lucas L van den Hoogen
- Dept of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht University, the Netherlands.
| | - Jacob M van Laar
- Dept of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht University, the Netherlands.
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Chighizola CB, Meroni PL. Thrombosis and Anti-phospholipid Syndrome: a 5-Year Update on Treatment. Curr Rheumatol Rep 2018; 20:44. [PMID: 29850957 DOI: 10.1007/s11926-018-0741-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an update of the therapeutic tools for thrombotic anti-phospholipid syndrome (APS), focusing on the last 5 years. RECENT FINDINGS Early studies appointed anticoagulation at moderate intensity as the mainstay of treatment of thrombotic APS; in the last 5 years, the strategy has not much mutated. Some uncertainties regarding the role of direct oral anticoagulants and the optimal regimen for arterial thrombotic APS still persist: high-intensity anticoagulation, anticoagulation plus anti-platelet agent, and double anti-platelet agents being the possible alternatives. Several drugs have been proposed as effective additional tools for the management of thrombotic APS: hydroxychloroquine, statins, vitamin D, and sirolimus might be beneficial when added on the top of anticoagulation. Pregnant women with thrombotic APS should be switched to low-dose aspirin plus low molecular weight heparin at therapeutic dose. Despite adequate treatment, APS patients display a significant rate of recurrences; rituximab, eculizumab, and intravenous immunoglobulins are among the options to be considered for these patients. From 2013 to date, the kaleidoscope of therapeutic options in thrombotic APS has been enriched, but tangible improvements in the management of patients are still awaited.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy. .,Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095, Cusano Milanino, Milan, Italy. .,Unit of Immunology, Allergology and Rheumatology, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milan, Italy.
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095, Cusano Milanino, Milan, Italy
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Dobrowolski C, Erkan D. Treatment of antiphospholipid syndrome beyond anticoagulation. Clin Immunol 2018; 206:53-62. [PMID: 29510235 DOI: 10.1016/j.clim.2018.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/02/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder marked by thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). At the present time, treatment is primarily focused on anticoagulation. However, there is increasing awareness of the mechanisms involved in APS pathogenesis, which has led to the trial of novel therapies targeting those mechanisms. Following a brief review of the etiopathogenesis of and current management strategies in APS, this paper focuses on the evidence for these potential, targeted APS treatments, e.g., hydroxychloroquine, statins, rituximab, belimumab, eculizumab, defibrotide, sirolimus, and peptide therapy.
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Affiliation(s)
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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Chighizola CB, Andreoli L, Gerosa M, Tincani A, Ruffatti A, Meroni PL. The treatment of anti-phospholipid syndrome: A comprehensive clinical approach. J Autoimmun 2018; 90:1-27. [PMID: 29449131 DOI: 10.1016/j.jaut.2018.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/06/2018] [Indexed: 01/02/2023]
Abstract
Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Allergology, Clinical Immunology and Rheumatology, Piazzale Brescia 20, 20149, Milan, Italy.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Department of Rheumatology, ASST Istituto Gaetano Pini & CTO, Piazza Cardinal Ferrari, 1 20122, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy
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Mora-Ramirez M, Gonzalez-Pacheco H, Amezcua-Guerra LM. The Impact of Primary Antiphospholipid Syndrome on Long-term Cardiovascular Outcomes After Percutaneous Coronary Intervention and Stenting in Patients With Myocardial Infarction. J Clin Rheumatol 2017; 24:169-173. [PMID: 29239935 DOI: 10.1097/rhu.0000000000000651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mauricio Mora-Ramirez
- Department of Immunology Instituto Nacional de Cardiología Ignacio Chávez Mexico City, Mexico Coronary Care Unit Instituto Nacional de Cardiología Ignacio Chávez Mexico City, Mexico Department of Health Care Universidad Autónoma Metropolitana - Xochimilco, Mexico City and La Salle School of Medicine Mexico City, Mexico
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Bal Dit Sollier C, Drouet L. [Involvement of thrombophilia in coronary thrombosis]. Ann Cardiol Angeiol (Paris) 2017; 66:365-372. [PMID: 29096905 DOI: 10.1016/j.ancard.2017.10.015] [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] [Indexed: 11/16/2022]
Abstract
This review of thrombophilia and coronary thrombosis takes into account the "classical" thrombophilia commonly found in venous pathology and the conditions under which their research may be useful in certain forms of arterial thrombosis especially coronary thrombosis. In addition to the classical thrombophilia, exceptional thrombophilia are evoked, which are both factors of venous thrombosis but also arterial thrombosis. There are also thrombophilia that are more specific to the arterial system such as - homocystein which is potentially both a thrombosis factor but also an agent of arterial parietal lesion or - serotonin which is a factor of arterial spasm and especially coronary spasm. Finally, under the term thrombophilia, it is possible to include thrombophilic conditions, in particular cancers and inflammatory conditions.
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Affiliation(s)
- C Bal Dit Sollier
- CREATIF (centre de référence et d'éducation aux antithrombotiques d'Île-de-France), service de cardiologie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - L Drouet
- CREATIF (centre de référence et d'éducation aux antithrombotiques d'Île-de-France), service de cardiologie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
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