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Li Q, Li J, Zhou M, Ge Y, Liu Z, Li T, Zhang L. Antiphospholipid antibody-related hepatic vasculitis in a juvenile after non-severe COVID-19: a case report and literature review. Front Immunol 2024; 15:1354349. [PMID: 38707895 PMCID: PMC11066154 DOI: 10.3389/fimmu.2024.1354349] [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: 12/12/2023] [Accepted: 03/29/2024] [Indexed: 05/07/2024] Open
Abstract
Antiphospholipid antibodies (aPL) are both laboratory evidence and causative factors for a broad spectrum of clinical manifestations of antiphospholipid syndrome (APS), with thrombotic and obstetric events being the most prevalent. Despite the aPL-triggered vasculopathy nature of APS, vasculitic-like manifestations rarely exist in APS and mainly appear associated with other concurrent connective tissue diseases like systemic lupus erythematous. Several studies have characterized pulmonary capillaritis related to pathogenic aPL, suggesting vasculitis as a potential associated non-thrombotic manifestation. Here, we describe a 15-year-old girl who develops hepatic infarction in the presence of highly positive aPL, temporally related to prior non-severe COVID-19 infection. aPL-related hepatic vasculitis, which has not been reported before, contributes to liver ischemic necrosis. Immunosuppression therapy brings about favorable outcomes. Our case together with retrieved literature provides supportive evidence for aPL-related vasculitis, extending the spectrum of vascular changes raised by pathogenic aPL. Differentiation between thrombotic and vasculitic forms of vascular lesions is essential for appropriate therapeutic decision to include additional immunosuppression therapy. We also perform a systematic review to characterize the prevalence and clinical features of new-onset APS and APS relapses after COVID-19 for the first time, indicating the pathogenicity of aPL in a subset of COVID-19 patients.
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Affiliation(s)
- Qingyu Li
- Tsinghua Medicine, School of Medicine, Tsinghua University, Beijing, China
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jingya Li
- Tsinghua Medicine, School of Medicine, Tsinghua University, Beijing, China
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Menglan Zhou
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Ying Ge
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhengyin Liu
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Taisheng Li
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Li Zhang
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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2
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Chighizola CB, Willis R, Maioli G, Sciascia S, Andreoli L, Amengual O, Radin M, Gerosa M, Atsumi T, de Jesus G, Trespidi L, Branch DW, Caporali R, Andrade D, Roubey R, Petri M, Bertolaccini ML. Deciphering the clinical significance of longitudinal antiphospholipid antibody titers. Autoimmun Rev 2024; 23:103510. [PMID: 38171447 DOI: 10.1016/j.autrev.2023.103510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
In antiphospholipid syndrome (APS), the risk of clinical manifestations increases with higher titers of antiphospholipid antibodies (aPL). Despite the adoption of aPL titers in the classification approach to aPL-positive subjects, the value of longitudinal monitoring of those titers in the follow-up is still debated, being well studied only in systemic lupus erythematosus (SLE). The literature suggests that the rate of aPL positivity decreases during follow-up in primary APS, estimating that seroconversion occurs in between 8.9 and 59% of patients over time. Negativisation of aPL occurs more frequently in asymptomatic aPL carriers than in patients with full-blown APS as well as in subjects with single aPL positivity or low aPL antibody titers. In patients with SLE, aPL typically behave fluctuating from positive to negative and back again in the course of follow-up. The few studies assessing the longitudinal course of aPL positivity with no associated systemic connective tissue disease reported a progressive decrement of aPL titers over time, in particular of antibodies against β2 glycoprotein I (antiβ2GPI) and cardiolipin (aCL) of IgG isotype. After a thrombotic event, aPL titers tend to decrease, as emerged from cohorts of both primary and secondary APS. Hydroxychloroquine has been identified as the most effective pharmacological agent to reduce aPL titers, with multiple studies demonstrating a parallel reduction in thrombosis rate. This review addresses available evidence on the significance of aPL titer fluctuation from clinical, therapeutic and pathogenic perspectives.
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Affiliation(s)
- Cecilia B Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Pediatric Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy.
| | - Rohan Willis
- University of Texas Medical Branch, Internal Medicine, Galveston, USA
| | - Gabriella Maioli
- Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | - Savino Sciascia
- University of Turin, Department of Clinical and Biological Sciences, Turin, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Olga Amengual
- Hokkaido University, Department of Rheumatology, Endocrinology and Nephrology Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Massimo Radin
- University of Turin, Department of Clinical and Biological Sciences, Turin, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | - Tatsuya Atsumi
- Hokkaido University, Department of Rheumatology, Endocrinology and Nephrology Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Guilherme de Jesus
- Universidade do Estado do Rio de Janeiro, Department of Obstetrics, Rio de Janeiro, Brazil
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, Pediatric Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | | | - Robert Roubey
- Department of Rheumatology, University of North Carolina, Chapel Hill, NC, USA
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Rheumatology, Baltimore, MD, USA
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3
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Cuadrado MJ, Tincani A, Enriquez Merayo E, Moschetti L, Sciascia S. Can anticoagulation be withdrawn in APS patients after aPL negativization? Autoimmun Rev 2024; 23:103427. [PMID: 37634679 DOI: 10.1016/j.autrev.2023.103427] [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: 08/07/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
Long-term vitamin K antagonist (VKA) anticoagulation is the cornerstone of the management of subjects with thrombotic antiphospholipid syndrome (APS). Recent investigations have opened up new discussion points regarding the potential for stopping anticoagulant medication in patients with a history of thrombotic APS who no longer have detectable aPL (the so called aPL negativization). Despite the lack of unanimous agreement, some experts agreed on defining aPL negativization as the presence of two negative determinations, 1 year apart. What to do in order to optimize the management of these subjects with thrombotic APS when aPL turn negative is still a matter of debate. In this review, we aim to summarize the main evidence highlighting the magnitude of aPL negativizing among patients with APS and the features to keep in mind when considering (or not) stopping anticoagulation.
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Affiliation(s)
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Dpt. of Clinical and Experimental Science, ASST-Spedali Civili and University of Brescia, Italy.
| | | | - Liala Moschetti
- Rheumatology and Clinical Immunology Unit, Dpt. of Clinical and Experimental Science, ASST-Spedali Civili and University of Brescia, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-ReConnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Department of Clinical and Biological Sciences, ASL Città Di Torino and University of Turin, Turin, Italy
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4
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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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5
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Yelnik C, Puigrenier S, Lambert M. Négativation des anticorps antiphospholipides et arrêt du traitement anticoagulant au cours du syndrome des antiphospholipides : qu’en penser ? Rev Med Interne 2022. [DOI: 10.1016/j.revmed.2022.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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6
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Sciascia S, Foddai SG, Alessandri C, Alunno A, Andreli L, Barinotti A, Calligaro A, Canti V, Carubbi F, Cecchi I, Chighizola CB, Conti F, Emmi G, Fioravanti A, Fischetti F, Franceschini F, Gerosa M, Hoxha A, Larosa M, Lazzaroni MG, Nalli C, Pazzola G, Radin M, Raffeiner B, Ramoni V, Rubini E, Sebastiani GD, Truglia S, Urban ML, Roccatello D, Tincani A. Clinical Delphi on aPLnegativization: report from the from the APS Study Group of the Italian Society for Rheumatology (SIR-APS). Thromb Haemost 2022; 122:1612-1620. [PMID: 35292950 DOI: 10.1055/a-1798-2400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The rate of antiphospholipid antibodies (aPL) negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion. Evaluate the clinical approach and level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario. Experts of SIR-APS were contacted using a survey methodology. A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost full consensus exist among experts in some clinical settings, including: a) the role of aPL negativization in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%); b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of "extra criteria" aPL antibodies testing before pondering VKA suspension (93%). A substantial agreement exists among expert on how to define aPL negativization. VKA suspension should be embraced with extreme caution, particularly in case of previous thrombotic events and/or triple aPL positivity. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for "extra criteria" is ruled out.
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Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy., University of Turin, Torino, Italy
| | - Silvia Grazietta Foddai
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy., University of Turin, Torino, Italy
| | - Cristiano Alessandri
- Lupus Clinic, Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy., University of Rome La Sapienza, Rome, Italy
| | - Alessia Alunno
- Internal Medicine and Nephrology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy, University of L'Aquila Department of Clinical Medicine Life Health and Environmental Sciences, L'Aquila, Italy
| | - Laura Andreli
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy., University of Brescia, Brescia, Italy
| | - Alice Barinotti
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy, University of Padua, Padova, Italy
| | - Valentina Canti
- Division of Immunology, IRCCS San Raffaele Scientific Institute, Milan, Italy, San Raffaele Hospital, Milano, Italy
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy., University of L'Aquila Department of Clinical Medicine Life Health and Environmental Sciences, L'Aquila, Italy
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Cecilia B Chighizola
- Division of Rheumatology, Department of Clinical Sciences and Community Health, Ospedale Gaetano Pini, University of Milan, Milan, Italy, University of Milan, Cusano Milanino, Italy
| | - Fabrizio Conti
- Lupus Clinic, Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy, University of Rome La Sapienza, Rome, Italy
| | - Giacomo Emmi
- Internal Interdisciplinary Medicine Unit, Lupus Clinic, Departmentof Experimental and Clinical Medicine, University of Firenze, Firenze, Italy, University of Florence, Firenze, Italy
| | - Antonella Fioravanti
- Rheumatology Unit, Department of Medicine, Surgery and Neuroscience, Azienda Ospedaliera Universitaria Senese, Siena, Italy, University of Siena, Siena, Italy
| | - Fabio Fischetti
- Rheumatology Unit, SUGI and Clinical University Department of Medical, Surgery and Health Sciences, University of Trieste, Italy, University of Trieste, Trieste, Italy
| | - Franco Franceschini
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, University of Brescia, Brescia, Italy
| | - Maria Gerosa
- Division of Rheumatology, Department of Clinical Sciences and Community Health, Ospedale Gaetano Pini, University of Milan, Milan, Italy, University of Milan, Milano, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy.,Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy, University of Padua, Padova, Italy
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy, University of Padua, Padova, Italy
| | - Maria-Grazia Lazzaroni
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, University of Brescia, Brescia, Italy
| | - Cecilia Nalli
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, University of Brescia, Brescia, Italy
| | - Giulia Pazzola
- Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia, Reggio Emilia, Italy, University of Modena e Reggio Emilia, Modena, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Bernd Raffeiner
- Rheumatology Unit, Department of Medicine, Bolzano, Italy, Free University of Bozen-Bolzano, Bolzano, Italy
| | - Veronique Ramoni
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, University of Pavia, Pavia, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Gian Domenico Sebastiani
- U.O.C. Reumatologia, Ospedale San Camillo-Forlanini, Roma, Italy, San Camillo Forlanini Foundation, Roma, Italy
| | - Simona Truglia
- Lupus Clinic, Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy, University of Rome La Sapienza, Rome, Italy
| | - Maria Letizia Urban
- Internal Interdisciplinary Medicine Unit, Lupus Clinic, Departmentof Experimental and Clinical Medicine, University of Firenze, Firenze, Italy, University of Florence, Firenze, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, University of Turin, Torino, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST SpedaliCivili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, University of Brescia, Brescia, Italy
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Pablo RD, Cacho PM, López-Hoyos M, Calvo-Río V, Riancho-Zarrabeitia L, Martínez-Taboada VM. Risk Factors for the Development of the Disease in Antiphospholipid Antibodies Carriers: A Long-term Follow-up Study. Clin Rev Allergy Immunol 2021; 62:354-362. [PMID: 34216367 PMCID: PMC8994711 DOI: 10.1007/s12016-021-08862-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 01/22/2023]
Abstract
The natural history of antiphospholipid antibodies (aPL) carriers is not well-established. The objectives of the present study were (a) to study the probability of developing clinical criteria of antiphospholipid syndrome (APS), (b) to identify potential risk factors for developing thrombosis and/or obstetric complications, (c) to study the association between the antibody profile and development of APS, and (d) to determine the efficacy of primary prophylaxis. We retrospectively analyzed 138 subjects with positive aPL who did not fulfill clinical criteria for APS. The mean follow-up time was 138 ± 63.0 months. Thirteen patients (9.4%) developed thrombosis after an average period of 73.0 ± 48.0 months. Independent risk factors for thrombosis were smoking, hypertension, thrombocytopenia, and triple aPL positivity. Low-dose acetyl salicylic acid did not prevent thrombotic events. A total of 28 obstetric complications were detected in 92 pregnancies. During the follow-up, only two women developed obstetric APS. Prophylactic treatment in pregnant women was associated with a better outcome in the prevention of early abortions. The thrombosis rate in patients with positive aPL who do not meet diagnostic criteria for APS is 0.82/100 patients-year. Smoking, hypertension, thrombocytopenia, and the aPL profile are independent risk factors for the development of thrombosis in aPL carriers. Although the incidence of obstetric complications in this population is high (31.6%), only a few of them meet APS criteria. In these women, prophylactic treatment might be effective in preventing early abortions.
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Affiliation(s)
- Rosalía Demetrio Pablo
- Servicio de Oftalmología, Hospital Universitario Marqués de Valdecilla, Cantabria, Spain
| | - Pedro Muñoz Cacho
- Gerencia de Atención Primaria IDIVAL, Servicio Cántabro de Salud, Cantabria, Spain.
| | - Marcos López-Hoyos
- Servicio de Inmunología, Hospital Universitario Marqués de Valdecilla, Cantabria, Spain.,Facultad de Medicina, Universidad de Cantabria, Santander, Spain
| | - Vanesa Calvo-Río
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla IDIVAL, Cantabria, Spain
| | | | - Víctor M Martínez-Taboada
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla IDIVAL, Cantabria, Spain.,Facultad de Medicina, Universidad de Cantabria, Santander, Spain
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8
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Pires Da Rosa G, Rodríguez-Pintó I, Cervera R, Espinosa G. Management of patients with antiphospholipid antibodies: what to do in laboratory scenarios that do not fit the guidelines. Expert Rev Hematol 2021; 14:457-466. [PMID: 33909986 DOI: 10.1080/17474086.2021.1923474] [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: 10/21/2022]
Abstract
Introduction: Some patients with positive antiphospholipid antibodies (aPL) have not been included in randomized clinical trials or observational registries and, therefore, information on their risk of obstetric or thrombotic recurrence and optimal treatment is scarce.Areas covered: In the present review, the existing evidence regarding the management of two laboratory scenarios not covered by the guidelines is presented: (1) patients with antiphospholipid syndrome (APS) clinical manifestations and aPL positivity not fulfilling APS laboratory criteria, and (2) the possibility of discontinuing anticoagulation in APS patients whose aPL become persistently negative.Expert opinion: Growing evidence suggests a role for low titers and 'non-criteria' aPL, especially in obstetric APS. Treatment is not formally recommended but might be considered according to the individual's risk profile. Regarding the question of whether or not to discontinue anticoagulants after the 'spontaneous' disappearance of aPL, there is no definite answer. Retrospective studies seem to suggest that withdrawal of anticoagulation could be safe in certain patients with APS, especially in those with a first provoked venous thrombosis and whose aPL became persistently negative during follow-up. Still, before the withdrawal can be recommended in routine clinical practice, multicenter and prospective studies are required to validate this hypothesis.
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Affiliation(s)
- Gilberto Pires Da Rosa
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ignasi Rodríguez-Pintó
- Autoimmune Diseases Unit, Hospital Universitari Mútua De Terrassa, Terrassa, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
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9
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Zen M, Doria A. Comment on: Prevalence, outcome and management of patients with SLE and secondary antiphospholipid antibody syndrome after aPL seroconversion: reply. Rheumatology (Oxford) 2021; 60:e115-e117. [PMID: 33280042 DOI: 10.1093/rheumatology/keaa800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Margherita Zen
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
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10
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The growing role of precision medicine for the treatment of autoimmune diseases; results of a systematic review of literature and Experts' Consensus. Autoimmun Rev 2020; 20:102738. [PMID: 33326854 DOI: 10.1016/j.autrev.2020.102738] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune diseases (AIDs) share similar serological, clinical, and radiological findings, but, behind these common features, there are different pathogenic mechanisms, immune cells dysfunctions, and targeted organs. In this context, multiple lines of evidence suggest the application of precision medicine principles to AIDs to reduce the treatment failure. Precision medicine refers to the tailoring of therapeutic strategies to the individual characteristics of each patient, thus it could be a new approach for management of AIDS which considers individual variability in genes, environmental exposure, and lifestyle. Precision medicine would also assist physicians in choosing the right treatment, the best timing of administration, consequently trying to maximize drug efficacy, and, possibly, reducing adverse events. In this work, the growing body of evidence is summarized regarding the predictive factors for drug response in patients with AIDs, applying the precision medicine principles to provide high-quality evidence for therapeutic opportunities in improving the management of these patients.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the diagnosis and management of the antiphospholipid syndrome (APS) in children. RECENT FINDINGS APS is a rare, acquired autoimmune systemic disease that can result in significant morbidity in children related to vascular thrombosis. The diagnosis and management of APS in children can be challenging due to a lack of validated diagnostic criteria and the rarity of the disease. In addition, many healthy children have transient circulating antiphospholipid antibodies without thrombotic complications. Nevertheless, epidemiological studies suggest that APS represents a greater relative proportion of thrombotic disease in children than it does in adults. Management of pediatric APS is largely inferred from adult data despite unique characteristics of pediatric APS. The current recommendations include long-term anticoagulation, which can be problematic in young, active individuals. There is little data on potential benefits of nonantithrombotic therapy in the management of pediatric APS. SUMMARY Data on pediatric APS are limited, but evidence suggests that using current available diagnostic testing is valuable and, until further evidence is available, treating thrombotic complications with heparins or warfarin should be standard of care.
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Zen M, Loredo Martinez M, Benvenuti F, Gatto M, Saccon F, Larosa M, Iaccarino L, Doria A. Prevalence, outcome and management of patients with SLE and secondary antiphospholipid antibody syndrome after aPL seroconversion. Rheumatology (Oxford) 2020; 60:1313-1320. [DOI: 10.1093/rheumatology/keaa463] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/21/2020] [Indexed: 02/06/2023] Open
Abstract
Abstract
Objective
The withdrawal of oral anticoagulation (OAC) in patients with SLE and secondary aPL syndrome (SAPS) who become seronegative has not been clearly investigated to date. Our aim was to evaluate the prevalence of aPL seroconversion and the prognosis of SLE patients with SAPS who withdrew OAC after aPL negativization.
Methods
We retrospectively analysed data of all SLE patients (ACR criteria) with SAPS (Sydney criteria) prospectively followed-up in our clinic. aPL seroconversion was defined as negativization of lupus anticoagulant, aCL, and anti-β2glycoprotein-1 antibodies on two or more consecutive measurements, at least 12 weeks apart. OAC discontinuation was defined as the definitive withdrawal of all anticoagulants.
Results
Fifty-five out of 513 (10.7%) SLE patients had vascular SAPS. Sixteen patients (29.1%) became aPL seronegative during follow-up. Immunosuppressive therapy predicted aPL negativization (odds ratio 5.211, 95%CI 1.341, 20.243), whereas APS diagnosis prior to that of SLE (odds ratio 0.078, 95%CI 0.008, 0.799) and triple-positive profile (odds ratio 0.264, 95%CI 0.115, 0.609) were negative predictors of aPL negativization. OAC was discontinued in 13/55 patients (23.6%), after a median follow-up of 45 months (range 1–276) from aPL seroconversion. SLE-related modifiable risk factors for thrombosis were observed in 10/13 patients (77%) at the time of the thrombotic event. No thrombotic recurrences were observed during a mean follow-up time of 44 (19) months from OAC discontinuation.
Conclusions
Our results suggest that OAC can be safely discontinued in SLE patients who became persistently seronegative for aPL, at least when aPL-related thrombotic events occurred in presence of other thrombotic risk factors.
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Affiliation(s)
- Margherita Zen
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Marta Loredo Martinez
- Division of Rheumatology, Lozano Blesa University Clinical Hospital, Zaragoza, Spain
| | - Francesco Benvenuti
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Francesca Saccon
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Maddalena Larosa
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Luca Iaccarino
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine DIMED, University of Padua, Padova, Italy
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Mesa CJ, Rife EC, Espinoza LR. Catastrophic antiphospholipid syndrome: is life-long anticoagulation therapy required? Clin Rheumatol 2020; 39:2115-2119. [PMID: 32107665 DOI: 10.1007/s10067-020-04997-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 11/30/2022]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is an unusual complication of antiphospholipid syndrome (APS) occurring in about 1% of patients. If left untreated, mortality can be as high as 50%. Therapy of APS and its complication CAPS is hampered by the lack of validated prospective, controlled, intervention clinical trials, although there is consensus that treatment should include anticoagulation therapy. But there are issues that need to be addressed such as duration and intensity of therapy. The present report describes our experience in 7 patients with CAPS in whom anticoagulation was discontinued after 6 months of therapy. During an average follow-up of 5.5 years, only 2 patients exhibited one episode each of recurrent venous thrombosis, but none of the patients in whom anticoagulation was discontinued experienced recurrent CAPS.Key Points• Discontinuation of long-term anticoagulation therapy in CAPS patients was not followed by recurrence of CAPS.
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Affiliation(s)
- Christopher J Mesa
- Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Eileen C Rife
- Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Luis R Espinoza
- Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, USA.
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Cheemalavagu S, McCoy SS, Knight JS. Digital ischaemia secondary to adalimumab-induced antiphospholipid syndrome. BMJ Case Rep 2020; 13:13/2/e232907. [PMID: 32041760 DOI: 10.1136/bcr-2019-232907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
A 50-year-old woman with a history of Crohn's disease treated with adalimumab presented with left hand pain and duskiness. Angiogram showed non-filling of the radial and digital arteries of the hand. Antiphospholipid antibody testing was positive, leading to a diagnosis of antitumour necrosis factor-induced antiphospholipid syndrome. Adalimumab was discontinued, and she was treated with the vitamin K antagonist warfarin and low-dose aspirin. Upon resolution of the antiphospholipid antibodies, she was transitioned to aspirin alone without recurrence of thrombosis.
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Affiliation(s)
| | - Sara S McCoy
- Division of Rheumatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jason S Knight
- Internal Medicine-Rheumatology, University of Michigan Hospital, Ann Arbor, Michigan, USA
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15
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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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Espinosa G, Coloma Bazán E, Cervera R. Cessation of oral anticoagulants in antiphospholipid syndrome. Lupus 2017; 26:1347-1348. [DOI: 10.1177/0961203317707829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- G Espinosa
- Department of Autoimmune Diseases, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Catalonia, Spain
| | - E Coloma Bazán
- Department of Autoimmune Diseases, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Catalonia, Spain
| | - R Cervera
- Department of Autoimmune Diseases, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Catalonia, Spain
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17
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Can we withdraw anticoagulation in patients with antiphospholipid syndrome after seroconvertion? Autoimmun Rev 2017; 16:1109-1114. [PMID: 28899804 DOI: 10.1016/j.autrev.2017.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 07/27/2017] [Indexed: 02/02/2023]
Abstract
The current mainstay of treatment in patients with thrombotic antiphospholipid syndrome (APS) is long-term anticoagulation, mainly with Vitamin K antagonist agents. Some recently available studies have created new ground for discussion about the possible discontinuation of anticoagulation therapy in patients with a history of thrombotic APS in whom antiphospholipid antibodies (aPL) are not detected any longer (i.e. aPL seroconversion). We report the main points discussed at the last CORA Meeting regarding the issue whether or not anticoagulation can be stopped after aPL seroconversion. In particular, we systematically reviewed the available evidence investigating the clinical outcome of APS patients with aPL seroconversion in whom anticoagulation was stopped when compared to those in whom therapy was continued regardless the aPL profile. Furthermore, the molecular basis for the aPL pathogenicity, the available evidence of non-criteria aPL and their association with thrombosis are addressed. To date, available evidence is still limited to support the indication to stop oral anticoagulation therapy in patients with a previous diagnosis of thrombotic APS who subsequently developed a negative aPL profile. The identification of the whole risk profile for cardiovascular manifestations and possibly of a second level aPL testing in selected patients with aPL might support the eventual clinical decision but further investigation is warranted.
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18
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Could Anticoagulation or Antiaggregation Treatment Be Ceased in Patients With Primary Antiphospholipid Syndrome When Antiphospholipid Antibodies Become Persistently Negative? J Clin Rheumatol 2017; 23:350-353. [DOI: 10.1097/rhu.0000000000000538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Anticoagulation withdrawal in antiphospholipid syndrome: a retrospective matched-control study. Lupus 2017; 27:357-364. [DOI: 10.1177/0961203317721751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background/Purpose Long-term anticoagulation is the standard treatment for thrombotic antiphospholipid syndrome (APS). However, in daily practice, the question of withdrawing anticoagulation may arise, without any evidence-based recommendations. This study aimed to assess outcomes in APS patients after anticoagulation withdrawal. Methods Thrombotic APS patients followed in our centre, whose anticoagulation was withdrawn after APS diagnosis, were retrospectively selected, and were match-controlled with patients under anticoagulation, based on sex, age, APS clinical phenotype and disease duration. Results Thirty cases with anticoagulation withdrawal were included. Median follow-up was 51 months (12–124). The risk of thrombotic relapse was higher in cases compared to controls (7.3% versus 1.5% patient-year ( p = 0.01); hazard ratio 4.8; 95% confidence interval (1.4–16.7)). Male gender, anti-β2GP1 and triple positivity at inclusion were predictive factors for thrombotic relapse. Conversely, aspirin prescription was a protective factor against relapses. Persistence of LA, anti-β2GP1 and triple positivity over time were associated with a higher risk of thrombosis and aPL disappearance with a lower risk. Conclusion In our study, anticoagulation withdrawal was associated with an increased risk of thrombotic relapse. Our findings emphasize the influence of anti-β2GP1 and triple positivity persistence over time on the risk of relapse and the benefit of aspirin prescription when anticoagulation has been withdrawn.
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20
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Medina G, Briones-García E, Cruz-Domínguez MP, Flórez-Durante OI, Jara LJ. Antiphospholipid antibodies disappearance in primary antiphospholipid syndrome: Thrombosis recurrence. Autoimmun Rev 2017; 16:352-354. [PMID: 28216071 DOI: 10.1016/j.autrev.2017.02.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 12/19/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the clinical outcome after aPL (antiphospholipid antibodies) disappearance in primary APS patients. METHODS From a cohort of 70 patients with primary APS, we selected patients with positive aPL determinations at onset and ≥2 subsequent negative aPL determinations during the last 5years. To corroborate the immunologic profile, we determined IgG/IgM aCL antibodies, IgG/IgM antiβ2GPl, anti-annexin A5 antibodies and lupus anticoagulant (LA). All patients continued treatment with oral anticoagulants. Clinical data and aPL determinations at onset/after disappearance were obtained. STATISTICAL ANALYSIS descriptive statistics and Kaplan-Meier analysis. RESULTS We found 24 patients with persistently negative aPL, including the last immunologic profile, 17 females, 7 males, mean age 51.7, disease evolution 16.3years, mean of 4 aPL previous positive determinations. aCL was positive at onset in 87.5%, 29% had double aPL positivity at onset (aCL/LA). Deep venous thrombosis (DVT) and ischemic stroke in 33% and pulmonary embolism in 12.5% were the most frequent manifestations at onset. INR range: 2-3. Time with aPL positive 109.4±80.7months. After 60months of follow-up since aPL disappearance, 45.8% of patients presented thrombosis recurrence, DVT in 9 patients, ischemic stroke in 1, pulmonary artery hypertension in 1. Other non-thrombotic APS manifestations were chronic ulcers in lower extremities and severe thrombocytopenia. CONCLUSIONS This study suggest, that in primary APS, persistent negative aPL profile is not an indication to interrupt oral anticoagulant therapy. However, there is a subset of patients that remained asymptomatic. Other studies are necessary in order to elucidate this controversy.
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Affiliation(s)
- Gabriela Medina
- Clinical Research Unit, Hospital de Especialidades Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico; Universidad Nacional Autónoma de México, Mexico City, Mexico.
| | | | - María Pilar Cruz-Domínguez
- Research Division, Hospital de Especialidades Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico; Universidad Nacional Autónoma de México, Mexico City, Mexico.
| | | | - Luis J Jara
- Direction of Education and Research, Hospital de Especialidades Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico; Universidad Nacional Autónoma de México, Mexico City, Mexico.
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21
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Renal involvement in primary antiphospholipid syndrome. J Nephrol 2016; 29:507-15. [PMID: 27198137 DOI: 10.1007/s40620-016-0317-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 05/03/2016] [Indexed: 12/13/2022]
Abstract
Antiphospholipid syndrome is an autoimmune disorder characterized by recurrent venous or arterial thrombosis and/or pregnancy-related problems associated with persistently elevated levels of antiphospholipid antibodies. The kidney is a major target organ in both primary and secondary antiphospholipid syndrome. This review describes several aspects of the renal involvement in the primary form of the syndrome, in particular the histological pattern of the so-called antiphospholipid syndrome nephropathy (APSN). APSN is a vascular nephropathy characterized by small vessel vaso-occlusive lesions associated with fibrous intimal hyperplasia of interlobular arteries, recanalizing thrombi in arteries and arterioles, and focal atrophy, a constellation of morphological lesions suggestive of primary antiphospholipid syndrome.
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Abstract
For patients with antiphospholipid syndrome (APS), the consensus is to treat those who develop thrombosis with long-term oral anticoagulation therapy and to prevent obstetric manifestations by use of aspirin and heparin. These recommendations are based on data from randomized controlled trials and observational studies. Despite this body of knowledge, areas of uncertainty regarding the management of APS exist where evidence is scarce or nonexistent. In other words, for a subset of patients the course of management is unclear. Some examples are patients with 'seronegative' APS, those who do not fulfil the formal (clinical or serological) classification criteria for definite APS, and those with recurrent thrombotic events despite optimal anticoagulation. Other challenges include the treatment of clinical manifestations not included in the classification criteria, such as haematologic manifestations (thrombocytopenia and haemolytic anaemia), neurologic manifestations (chorea, myelitis and multiple sclerosis-like lesions), and nephropathy and heart valve disease associated with antiphospholipid antibodies (aPL), as well as the possible withdrawal of anticoagulation treatment in selected cases of thrombotic APS in which assays for aPL become persistently negative. This Review focuses on the current recommendations for thrombotic and obstetric manifestations of APS, as well as the management of difficult cases. Some aspects of treatment, such as secondary prophylaxis of venous thrombosis, are based on strong evidence--the 'lights' of APS treatment. Conversely, other areas, such as the treatment of non-criteria manifestations of APS, are based only on expert consensus or common sense and remain the 'shadows' of APS therapy.
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Chighizola CB, Ubiali T, Meroni PL. Treatment of Thrombotic Antiphospholipid Syndrome: The Rationale of Current Management-An Insight into Future Approaches. J Immunol Res 2015; 2015:951424. [PMID: 26075289 PMCID: PMC4436516 DOI: 10.1155/2015/951424] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 04/15/2015] [Indexed: 11/18/2022] Open
Abstract
Vascular thrombosis and pregnancy morbidity represent the clinical manifestations of antiphospholipid syndrome (APS), which is serologically characterized by the persistent positivity of antiphospholipid antibodies (aPL). Antiplatelet and anticoagulant agents currently provide the mainstay of APS treatment. However, the debate is still open: controversies involve the intensity and the duration of anticoagulation and the treatment of stroke and refractory cases. Unfortunately, the literature cannot provide definite answers to these controversial issues as it is flawed by many limitations, mainly due to the recruitment of patients not fulfilling laboratory and clinical criteria for APS. The recommended therapeutic management of different aPL-related clinical manifestations is hereby presented, with a critical appraisal of the evidence supporting such approaches. Cutting edge therapeutic strategies are also discussed, presenting the pioneer reports about the efficacy of novel pharmacological agents in APS. Thanks to a better understanding of aPL pathogenic mechanisms, new therapeutic targets will soon be explored. Much work is still to be done to unravel the most controversial issues about APS management: future studies are warranted to define the optimal management according to aPL risk profile and to assess the impact of a strict control of cardiovascular risk factors on disease control.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Immunology Research Laboratory, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Tania Ubiali
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy
- Division of Rheumatology, Istituto Ortopedico Gaetano Pini, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
| | - Pier Luigi Meroni
- Immunology Research Laboratory, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy
- Division of Rheumatology, Istituto Ortopedico Gaetano Pini, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
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25
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Discontinuation of anticoagulation or antiaggregation treatment may be safe in patients with primary antiphospholipid syndrome when antiphospholipid antibodies became persistently negative. Immunol Res 2013; 56:358-61. [DOI: 10.1007/s12026-013-8407-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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26
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Ruiz-Irastorza G, Cuadrado MJ, Ruiz-Arruza I, Brey R, Crowther M, Derksen R, Erkan D, Krilis S, Machin S, Pengo V, Pierangeli S, Tektonidou M, Khamashta M. Evidence-based recommendations for the prevention and long-term management of thrombosis in antiphospholipid antibody-positive patients: report of a task force at the 13th International Congress on antiphospholipid antibodies. Lupus 2011; 20:206-18. [PMID: 21303837 DOI: 10.1177/0961203310395803] [Citation(s) in RCA: 322] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The antiphospholipid syndrome (APS) is defined by the presence of thrombosis and/or pregnancy morbidity in combination with the persistent presence of circulating antiphospholipid antibodies: lupus anticoagulant, anticardiolipin antibodies and/or anti-β2-glycoprotein I antibodies in medium to high titers. The management of thrombosis in patients with APS is a subject of controversy. This set of recommendations is the result of an effort to produce guidelines for therapy within a group of specialist physicians in Cardiology, Neurology, Hematology, Rheumatology and Internal Medicine, with a clinical and research focus on APS.
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Affiliation(s)
- G Ruiz-Irastorza
- Autoimmune Disease Research Unit, Department of Internal Medicine, Hospital de Cruces, University of the Basque Country, Barakaldo, Spain.
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Abstract
The antiphospholipid syndrome is defined by the presence of antiphospholipid antibodies in patients with recurrent venous or arterial thromboembolism or pregnancy morbidity. Antithrombotic therapies are the mainstay of treatment to reduce the risk of recurrent thromboembolism. Among patients with antiphospholipid antibodies, the absolute risk of new thrombosis developing is low in healthy patients without previous thrombotic events. However, the risk of recurrent thrombosis appears to be high in patients with a history of arterial or venous thrombosis. Compared with placebo or untreated control, anticoagulation with warfarin administered to achieve an international normalized ratio of 2.0 to 3.0 probably reduces the risk of recurrence of thrombotic events. Aspirin and moderate-intensity warfarin appear equally effective for preventing recurrent stroke in patients with a single positive antiphospholipid antibody test result and previous stroke. It is unknown how best to prevent first stroke in patients found to be persistently positive for the antiphospholipid syndrome. The catastrophic variant of the antiphospholipid syndrome is a condition characterized by multiple vascular occlusive events, usually affecting small vessels and evolving over a short period of time. This condition has a very high mortality rate. First-line treatment with therapeutic anticoagulation, corticosteroids, plasma exchange, and intravenous immunoglobulin seems to be effective in reducing mortality and risk of catastrophic thrombotic events in these patients. In conclusion, moderate-intensity warfarin is effective for preventing recurrent thrombotic events in patients with venous thrombosis. Aspirin appears to be as effective as moderate-intensity warfarin for preventing recurrent stroke in patients with previous stroke and a single positive test result for antiphospholipid antibody. The optimal treatment of other clinical manifestations of antiphospholipid syndrome needs to be addressed in well-designed prospective studies.
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28
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Rodríguez-Fernández S, Saavedra Ramírez P, Espinosa Garriga G, Cervera Segura R. [Suspension of anticoagulation in patients with primary antiphospholipid syndrome in which a negative antibody antiphospholipid]. Rev Clin Esp 2009; 209:357-8. [PMID: 19709543 DOI: 10.1016/s0014-2565(09)71823-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Espinosa G, Cervera R. Thromboprophylaxis and obstetric management of the antiphospholipid syndrome. Expert Opin Pharmacother 2009; 10:601-14. [DOI: 10.1517/14656560902772302] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Antiphospholipid syndrome is diagnosed when arterial or venous thrombosis or recurrent miscarriages occur in a person in whom laboratory tests for antiphospholipid antibodies (anticardiolipin antibodies and/or lupus anticoagulant and/or anti-beta 2-glycoprotein I) are positive. Despite the strong association between antiphospho-lipid antibodies and thrombosis, their pathogenic role in the development of thrombosis has not been fully elucidated. Novel mechanisms involving both the complement pathway and micro-particles have been described. The knowledge of these new pathogenic approaches might identify novel therapeutic targets and therefore may improve the management of these patients.
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Affiliation(s)
- Gerard Espinosa
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Catalonia, Spain.
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