Thrombocytopenia in antiphospholipid syndrome: Is anticoagulation and/or antiaggregation always required?

The antiphospholipid syndrome (APS) is an autoimmune and prothrombotic condition defined by the association of thrombotic events and/or obstetrical complications and the persistence of antiphospholipid antibodies (aPL) over time. Among the new criteria recently included in the 2023 ACR/EULAR classification criteria for APS, thrombocytopenia is one of the most frequent. The occurrence of thrombocytopenia in aPL/APS patients is important to consider because it could predict APS-related clinical events with a 3-fold increased risk for thrombotic events or obstetrical morbidity or all-cause deaths. A debate on the need or not of anticoagulation and/or antiaggregation in APS patients and aPL carriers with thrombocytopenia took place on the 7th edition of the International Congress on Controversies in Rheumatology and Autoimmunity (CORA), that was organized in Turin, Italy, on March 18th, 2023, and this review summarizes the main arguments that were discussed in this session.

AB1309 ANALYSIS OF A MONOCENTRIC COHORT OF IgG4-RELATED DISEASE PATIENTS: GREATER REDUCTION OF THE RESPONDER INDEX IN PHARMACOLOGICALLY-TREATED PATIENTS AS COMPARED TO UNTREATED ONES

Background

IgG4-related disease (IgG4-RD) is a systemic disease characterized by lymphoplasmocellular infiltration and storiform fibrosis. Pancreas, biliary tract, lacrimal and salivary glands, lymph nodes and retroperitoneum are frequently involved, although the clinical presentation may vary [1].

Objectives

The aim of this study is to retrospectively describe the clinical manifestations of a monocentric cohort of patients with IgG4-RD and analyze their clinical course by applying the validated IgG4-Related Disease Responder Index (RI) [2].

Methods

We enrolled 22 IgG4-RD patients classified with 2011 diagnostic criteria [3] and/or 2019 classification criteria [4].

Results

22 IgG4-RD patients (M/F=3.4/1), mostly Caucasian (91%), were diagnosed at a mean age of 59 years (44-74) with a median IgG4 concentration at diagnosis of 239 mg/dl (IQR 106-391 mg/dL). 14/22 (64%) patients fulfilled the 2011 classification criteria, while 8/22 (36%) were classified as possible (2), probable (5) or definitive (1) according to the diagnostic criteria of 2011. Organ involvement at diagnosis (T0) is described in Table 1. The organs most involved were lymph nodes, salivary glands and retroperitoneum. Patients were followed for a median of 49 months (IQR 16-88). Three patients were lost to follow-up. One patient died for pneumonia 96 months after diagnosis. During the follow-up 5 (23%) patients didn’t receive specific treatment, 1 (5%) was treated surgically, 6 (27%) with steroid only, 10 (45%) with steroid and immunosuppressants (with methotrexate and/or rituximab, tocilizumab, mycophenolate, cyclosporine, hydroxychloroquine, azathioprine) and/or surgical resection. A statistically significant reduction in RI between T0 and last follow-up (TLF) was observed in all the patients [from 6 (3-6) to 3 (1-4) p=0.010]. A significant reduction was also observed in the group of pharmacologically treated patients [from 6 (3-6) to 3 (1-4) p=0.035] but not in the group of patients without drug treatment (p = 0.174).

Table 1.

Organ involvement at diagnosis

Organ involvement T0N. Patients (%)Pancreas2 (9)Lymph nodes14 (64)Salivary glands13 (59)Lungs1 (5)Aorta and large blood vessels4 (18)Retroperitoneum, mediastinum, mesentery6 (27)Bile duct and liver3 (14)Kidneys2 (9)Pachymeninges1 (5)Orbits and lacrimal glands3 (14)Paranasal sinuses and / or nasal mucosa5 (23)

Conclusion

In our cohort, patients were predominantly male with mean age at diagnosis of 59 years, consistent with literature data [1]. A statistically significant reduction in disease activity defined by reduction of RI was observed in patients who received immunosuppressive therapy. No significant reduction was observed in patients not pharmacologically treated.

References

[1]Dai Inoue et al. Medicine, 2015

[2]Carruthers M.N. et al. Int J Rheumatol, 2012

[3]Umehara H. et al. Mod Rheumatol, 2012

[4]Wallace Z.S. et al. Ann Rheum Dis, 2020

Disclosure of Interests

None declared

AB1109 EVALUATION OF THE POTENTIAL INDUCTION OF AUTOANTIBODIES AFTER THE ANTI-SARS-COV2-VACCINATION IN A COHORT OF PATIENTS WITH TRIPLE POSITIVITY FOR ANTIPHOSPHOLIPID ANTIBODIES

Background

Anti-SARS-CoV2 vaccines showed a good efficacy in prevention of severe COVID-191. Their potential in induction of autoantibodies (abs) has not been well established1. One recent study demonstrated an increase of abs’ titre after anti-SARS-CoV2 vaccination only in patients with already pre-existing positivity2.

Objectives

To evaluate the potential induction of abs after anti-SARS-CoV2 vaccination in a triple positive antiphospholipid antibodies (aPL) cohort.

Methods

18 subjects were enrolled [M/F= 17/1; median age=52 years; 5 Primary Antiphospholipid Syndrome (PAPS), 5 Systemic Lupus Erythematosus (SLE) with associated APS and 8 aPL carriers (1 Behçet Disease, 1 SLE, 4 Undifferentiated Connective Tissue Disease, 2 with no diagnosis of systemic autoimmune disease)]. Serum samples were collected before the first (T0) and at least one month after the second administration (T1) of the anti-SARS-CoV2 vaccine (16 BNT162b2, 1 mRNA-1273, 1 Gam-COVID-Vac).

A wide panel of abs were evaluated through routinely methods.

Results

None developed any additional sign of autoimmune diseases upon vaccination. Patients majority did not display any new autoantibody positivity (Table 1). Changes were observed in 3 patients: 1) one aPL carrier patient who was antinuclear antibodies (ANA) negative at T0 was found to be ANA positive at T1 [negative anti-double stranded DNA and anti-extractable nuclear antigen (ENA)]; this patient was actually ANA positive in her clinical history; 2) one aPL carrier patient affected by SLE, who was IgM and IgG aCL and IgG aB2GPI positive at T0, turned positive for IgM and IgA aB2GPI; 3) one aPL carrier patient affected by Behçet Disease, who was positive for IgM aCL and for IgM aB2GPI at T0, turned positive for IgA aCL and IgA aB2GPI.

Table 1.

Autoantibodies’ titre pre (T0) and post (T1) anti-SARS-CoV2 vaccination.

AutoantibodiesLevel at T0Level at T1p-value*Patients positive at T0Patients positive at T1p-value°Anti-dsDNA28.7 (21.8-64.5)25.8 (15.9-68.5)0.1637/18 (38.9%)6/18 (33.3%)0.729(n.v. <27 IU/ml)aCL IgG88.1 (27.1-218.9)68.2 (18.8-181.3)0.11815/18 (83.3%)13/18 (72.2%)0.691(n.v. <20 CU)aCL IgG11.9 (11.2-77.2)11.2 (11.2-24.5)0.4329/18 (50%)7/18 (38.9%)0.502(n.v. <12 IU/ml)aCL IgM20.8 (5.9-35.9)8.9 (3.3-21.6)0.0069/18 (50%)5/18 (27.8%)0.171(n.v. <20 CU)aCL IgM30.4 (18.1-170.8)23.8 (11.2-82.3)0.02914/18 (77.8%)12/18 (66.7%)0.457(n.v. <12 IU/ml)aCL IgA11.7 (11.2-30.9)11.2 (11.2-17.6)0.0298/18 (44.4%)6/18 (33.3%)0.494(n.v. <12 IU/ml)aβ2GPI IgG230.4 (110.1-971.1)242.3 (33.7-652.9)0.08316/18 (88.9%)14/18 (77.8%)0.658(n.v. <20 CU)aβ2GPI IgG9.3 (9.3-128.1)19.4 (9.3-126.9)0.8448/18 (44.4%)9/18 (50%)0.738(n.v. <20 IU/ml)aβ2GPI IgM16.9 (3.6-51.3)6.8 (1.5-23.1)0.0417/18 (38.9%)5/18 (27.8%)0.480(n.v. <20 CU)aβ2GPI IgM19.8 (11.1-78.8)9.9 (9.3-52.4)0.1098/18 (44.4%)7/18 (38.9)0.735(n.v. <20 IU/ml)aβ2GPI IgA20.8 (9.3-39.9)9.3 (9.3-37.8)0.08010/18 (55.6%)7/18 (38.9%)0.317(n.v. <20 IU/ml)

Antiphospholipid antibodies were determined with chemiluminescence (CU) and home-made ELISA (IU/ml) methods of detection. Pre and post-vaccine values are expressed as median (IQR). In bold, statistically significant comparisons. *Wilcoxon signed-rank test for paired variables was applied. °Chi-square test or Fisher’s exact test were applied.

dsDNA=double-stranded DNA; aCL: anti-cardiolipin; aβ2GPI: anti-beta2-glycoprotein I; n.v.: normal value.

All emerging aPL were low titre. None of the patients displayed raising aPL titres from low to medium-high.

Conclusion

Anti-SARS-CoV2 vaccination did not induce any clinical signs of autoimmunity in a cohort of patients with triple aPL positivity. Serology for autoantibodies remained stable in the majority of patients. Few patients experienced the emergence of low titre aPL, possibly as an expected inter-assay variation rather than an evolving “serological flare”.

References

[1]Ishay Y et al. Int Immunopharmacol. 2021;

[2]Thurm C et al. medRxiv 2021.

Disclosure of Interests

None declared

C11 DAE RESPONDER APP IN PIACENZA: AN INTEGRATED RESCUE NETWORK AGAINST CARDIAC ARREST USING THE TECHNOLOGY AVAILABLE FOR DAE RESPONDERS CITIZENS

Introduction

Early Defibrillation is the most effective method for resuscitation in patients with out of hospital cardiac arrest(OHCA). The presence of shockable rhythm is an important determinant of survival, therefore, the implementation of systems that increase the likelihood of immediate CPR and rapid defibrillation are vital to improving survival. To this end, in 2017 the DAE REsponder APP (ADR) was developed to alert the trained citizens nearest to the scene and direct them to the closest DAE.

Aim

To evaluate the performance of this application in terms of number of interventions and number of patients saved. Methods: Since 2014, the Emilia Romagna region created a regional portal dedicated to the OHCA the AED REspondER emergency, in which each province registered the automated external defibrillators (AEDs), indicating their geolocation and accessibility. From this system was developed the ADR, which can be used by every citizen through their smartphone. ADR has several functions: alerting the DR citizens closest to the victim, possibility to choose whether to intervene or not, in case of acceptance, navigation to the place and to the AED closer.

Results

In Piacenza 1046 AEDs have been placed and 1212 people are registered as DR.From 2018, 525 blue codes have been activated (out of a regional total of 4457) and 80560 notifications have been sent to DRs: in 145 cases (27.62%)the intervention was accepted, in 19 cases DR arrived before 118 and in 12 cases the AED was applied (63.16%) with 7(55%) patients survived.

Conclusion

The ADR could be considered an effective method to deliver an immediate CPR and increase the chance of survival in case of OHCA.

Managing puerperium in patients with systemic autoimmune diseases: an update

INTRODUCTION

Puerperium is a critical period for patients affected by autoimmune rheumatic diseases for the risk of disease's flares and difficulties in treating lactating mothers. We want to summarize the literature data about psychological and pharmacological management of these patients and possible risk factors of disease's flares.

AREAS COVERED

We made a narrative review on recent studies about puerperium in rheumatic autoimmune diseases patients.

EXPERT OPINION

The physicians involved in management of patients during puerperium and in the follow-up of babies need to agree on maternal treatment because they need to reassure mothers about the safety of the prescribed medications. Furthermore, women with rheumatic diseases could present some musculoskeletal limitations and psychological problems, such as postpartum depression, which can lead to a sense of inadequacy to the mother's task. Families and physicians should be aware of these possible complications and support the new mothers providing correct counseling and practical help.

[Rational medical and surgical therapy of essential facial hemispasm. Experiences in 21 cases]

After a brief review of the definition, aetiopathogenetic hypotheses and various medical and surgical treatment of idiopathic hemifacial spasm, 21 personal cases are reported. It is concluded that the most effective treatment is surgical release of the compressed nerve with various types of vascular loop. The most effective medical treatment is large doses of carbamazepine, though it does not always produce a lasting improvement.