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Andreoli L, Gerardi MC, Gerosa M, Rozza D, Crisafulli F, Erra R, Lini D, Trespidi L, Padovan M, Ruffilli F, Serale F, Cuomo G, Raffeiner B, Semeraro P, Tani C, Chimenti MS, Conigliaro P, Hoxha A, Nalli C, Fredi M, Lazzaroni MG, Filippini M, Taglietti M, Franceschini F, Zatti S, Loardi C, Orabona R, Ramazzotto F, Zanardini C, Fontana G, Gozzoli G, Barison C, Bizioli P, Caporali RF, Carrea G, Ossola MW, Maranini B, Silvagni E, Govoni M, Morano D, Verteramo R, Doria A, Del Ross T, Favaro M, Calligaro A, Tonello M, Larosa M, Zen M, Zambon A, Mosca M, Zucchi D, Elefante E, Gori S, Iannone F, Anelli MG, Lavista M, Abbruzzese A, Fasano CG, D'Angelo S, Cutro MS, Picerno V, Carbone T, Padula AA, Rovere-Querini P, Canti V, De Lorenzo R, Cavallo L, Ramoni V, Montecucco C, Codullo V, Milanesi A, Pazzola G, Comitini G, Marvisi C, Salvarani C, Epis OM, Benedetti S, Di Raimondo G, Gagliardi C, Lomater C, Crepaldi G, Bellis E, Bellisai F, Garcia Gonzalez E, Pata AP, Zerbinati M, Urban ML, Mattioli I, Iuliano A, Sebastiani G, Brucato AL, Bizzi E, Cutolo M, Santo L, Tonetta S, Landolfi G, Carrara G, Bortoluzzi A, Scirè CA, Tincani A. Management of pregnancy in autoimmune rheumatic diseases: maternal disease course, gestational and neonatal outcomes and use of medications in the prospectiveItalian P-RHEUM.it study. RMD Open 2024; 10:e004091. [PMID: 38663885 PMCID: PMC11043763 DOI: 10.1136/rmdopen-2024-004091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVES To investigate pregnancy outcomes in women with autoimmune rheumatic diseases (ARD) in the Italian prospective cohort study P-RHEUM.it. METHODS Pregnant women with different ARD were enrolled for up to 20 gestational weeks in 29 Rheumatology Centres for 5 years (2018-2023). Maternal and infant information were collected in a web-based database. RESULTS We analysed 866 pregnancies in 851 patients (systemic lupus erythematosus was the most represented disease, 19.6%). Maternal disease flares were observed in 135 (15.6%) pregnancies. 53 (6.1%) pregnancies were induced by assisted reproduction techniques, 61 (7%) ended in miscarriage and 11 (1.3%) underwent elective termination. Obstetrical complications occurred in 261 (30.1%) pregnancies, including 2.3% pre-eclampsia. Two cases of congenital heart block were observed out of 157 pregnancies (1.3%) with anti-Ro/SSA. Regarding treatments, 244 (28.2%) pregnancies were treated with glucocorticoids, 388 (44.8%) with hydroxychloroquine, 85 (9.8%) with conventional synthetic disease-modifying anti-rheumatic drugs and 122 (14.1%) with biological disease-modifying anti-rheumatic drugs. Live births were 794 (91.7%), mostly at term (84.9%); four perinatal deaths (0.5%) occurred. Among 790 newborns, 31 (3.9%) were small-for-gestational-age and 169 (21.4%) had perinatal complications. Exclusive maternal breast feeding was received by 404 (46.7%) neonates. The Edinburgh Postnatal Depression Scale was compiled by 414 women (52.4%); 89 (21.5%) scored positive for emotional distress. CONCLUSIONS Multiple factors including preconception counselling and treat-to-target with pregnancy-compatible medications may have contributed to mitigate disease-related risk factors, yielding limited disease flares, good pregnancy outcomes and frequency of complications which were similar to the Italian general obstetric population. Disease-specific issues need to be further addressed to plan preventative measures.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Chiara Gerardi
- Division of Rheumatology, Multispecialist Medical Department, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Gerosa
- Clinical Rheumatology Division, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, REsearch Center for Adult and Pediatric Rheumatic Diseases (RECAP-RD), University of Milan, Milan, Italy
| | - Davide Rozza
- Epidemiology Research Unit of the Italian Society for Rheumatology, Milan, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberta Erra
- Department of Obstetrics and Gynaecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Lini
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Melissa Padovan
- Rheumatology Unit, Azienda Ospedaliero-Universitaria S. Anna - Ferrara, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Francesca Ruffilli
- Rheumatology Unit, Azienda Ospedaliero-Universitaria S. Anna - Ferrara, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Giovanna Cuomo
- Precision Medicine Department, University of Campania L. Vanvitelli, Naples, Italy
| | - Bernd Raffeiner
- Department of Rheumatology, Central Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University (PMU), Bolzano, Italy
| | - Paolo Semeraro
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Chiara Tani
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Sole Chimenti
- Department of Systems Medicine, Rheumatology, Allergology and Clinical Immunology, University of Rome Tor Vergata, Rome, Italy
| | - Paola Conigliaro
- Department of Systems Medicine, Rheumatology, Allergology and Clinical Immunology, University of Rome Tor Vergata, Rome, Italy
| | - Ariela Hoxha
- General Medicine and Thrombosis and Hemorrhagic Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Micaela Fredi
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Matteo Filippini
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Taglietti
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sonia Zatti
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Chiara Loardi
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Rossana Orabona
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | | | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Giulia Fontana
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Giorgia Gozzoli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudia Barison
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paola Bizioli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Felice Caporali
- Clinical Rheumatology Division, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, REsearch Center for Adult and Pediatric Rheumatic Diseases (RECAP-RD), University of Milan, Milan, Italy
| | - Giulia Carrea
- Clinical Rheumatology Division, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, REsearch Center for Adult and Pediatric Rheumatic Diseases (RECAP-RD), University of Milan, Milan, Italy
| | - Manuela Wally Ossola
- Department of Obstetrics and Gynaecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Beatrice Maranini
- Rheumatology Unit, Azienda Ospedaliero-Universitaria S. Anna - Ferrara, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Ettore Silvagni
- Rheumatology Unit, Azienda Ospedaliero-Universitaria S. Anna - Ferrara, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Marcello Govoni
- Rheumatology Unit, Azienda Ospedaliero-Universitaria S. Anna - Ferrara, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Danila Morano
- Dipartimento Materno Infantile, Obstetrics and Gynecology Unit, Azienda Ospedaliero-Universitaria S. Anna, University of Ferrara, Ferrara, Italy
| | - Rosita Verteramo
- Dipartimento Cure Primarie, UO Servizi Sanitari 1- AUSL Ferrara, Ferrara, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, Arenzano, Genoa, Italy
| | - Margherita Zen
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Alessandra Zambon
- Unit of Obstetrics and Gynecology, Department of Woman and Child Health, University of Padova, Padova, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dina Zucchi
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elena Elefante
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Sabrina Gori
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | | | - Marlea Lavista
- Rheumatology Unit, DiMePRE-J, University of Bari, Bari, Italy
| | - Anna Abbruzzese
- Rheumatology Unit, DiMePRE-J, University of Bari, Bari, Italy
| | | | | | | | - Valentina Picerno
- Rheumatology Department of Lucania - San Carlo Hospital, Potenza, Italy
| | - Teresa Carbone
- Immunopathology Laboratory, San Carlo Hospital, Potenza, Italy
| | | | - Patrizia Rovere-Querini
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Valentina Canti
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rebecca De Lorenzo
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ludovica Cavallo
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Véronique Ramoni
- Internal Medicine Department, ASST Lodi - Ospedale Maggiore di Lodi, Lodi, Italy
| | | | - Veronica Codullo
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandra Milanesi
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- PhD Program in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Giulia Pazzola
- Rheumatology Unit, Azienda USL IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giuseppina Comitini
- Department of Obstetrics and Gynecology, Azienda USL IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Chiara Marvisi
- Rheumatology Unit, Azienda USL IRCCS di Reggio Emilia, Reggio Emilia, Italy
- PhD Program in Clinical Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Department of Surgery, Medicine, Dentistry and Morphological Sciences with interest in Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Oscar Massimiliano Epis
- Division of Rheumatology, Multispecialist Medical Department, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Sara Benedetti
- Obstetrics and Gynecology, Maternal Infant Department, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppina Di Raimondo
- Obstetrics and Gynecology, Maternal Infant Department, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Clizia Gagliardi
- Division of Rheumatology, Multispecialist Medical Department, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Lomater
- Academic Rheumatology Center, A.O. Mauriziano di Torino; Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Gloria Crepaldi
- Academic Rheumatology Center, A.O. Mauriziano di Torino; Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Elisa Bellis
- Academic Rheumatology Center, A.O. Mauriziano di Torino; Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Francesca Bellisai
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Estrella Garcia Gonzalez
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Anna Paola Pata
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Martina Zerbinati
- General Medicine and Thrombosis and Hemorrhagic Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Irene Mattioli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | | | - Antonio Luca Brucato
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Emanuele Bizzi
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, Milan, Italy
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, IRCCS San Martino Polyclinic Hospital, Genova, Italy
| | - Leonardo Santo
- Rheumatology Unit, "Mons. Dimiccoli" Hospital, Barletta (BT), Italy
| | - Sara Tonetta
- Unit of Rheumatology, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Gianpiero Landolfi
- Epidemiology Research Unit of the Italian Society for Rheumatology, Milan, Italy
| | - Greta Carrara
- Epidemiology Research Unit of the Italian Society for Rheumatology, Milan, Italy
| | - Alessandra Bortoluzzi
- Epidemiology Research Unit of the Italian Society for Rheumatology, Milan, Italy
- Rheumatology Unit, Azienda Ospedaliero-Universitaria S. Anna - Ferrara, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Carlo Alberto Scirè
- Epidemiology Research Unit of the Italian Society for Rheumatology, Milan, Italy
- Rheumatology Unit, IRCCS San Gerardo dei Tintori Foundation, Milan, Italy
- School of Medicine, Bicocca University, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Hoxha A, Perin N, Lovisotto M, Calligaro A, Del Ross T, Favaro M, Tonello M, Doria A, Simioni P. Risk factors for damage accrual in primary antiphospholipid syndrome: A retrospective single-center cohort study. J Autoimmun 2024; 144:103180. [PMID: 38368768 DOI: 10.1016/j.jaut.2024.103180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Despite anticoagulant therapy, a antiphospholipid syndrome (APS) has a higher rate of recurrent events, which can lead to damage accrual and a negative impact on life quality. OBJECTIVES To evaluate the risk factors and APS subsets associated with damage accrual. PATIENTS/METHODS We conducted a retrospective single-center study. We reviewed the medical records of 282 APS patients, with a median age of 36 (IQR 30-46) years and a median of 195 (IQR 137-272) months. The primary endpoint was damage accrual during follow-up, defined as organ/tissue impairment present for at least six months or causing permanent loss. The secondary endpoints were early organ damage within six months of disease onset and death. RESULTS Eighty (28.4%) patients presented damage accrual; 52.5% developed damage within six months of APS onset, and 41.3% had more than one organ involved. Neuropsychiatric involvement, affecting 38.8% of the patients, was the most frequent, followed by peripheral vasculopathy and renal involvement, 35% either. Death happened in 7 (2.5 %) patients; damage accrual was associated with a 6-fold risk of death [OR 6.7 (95% CI 1.3-35.1), p = 0.03]. Microangiopathy and non-criteria manifestations were independent risk factors for damage accrual with 5-fold and 4-fold higher risk, respectively [(OR 4.9 (95% CI 2.1-11.7), p < 0.0001 and (OR 3.8 (95% CI 1.5-10.1), p = 0.007]. The cumulative incidence of damage accrual increased by 5.7-fold and 3.6-fold in patients with microangiopathy and non-criteria manifestations. CONCLUSIONS APS patients had a higher frequency of damage accrual. Microangiopathy and non-criteria manifestations were independent risk factors for damage accrual.
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Affiliation(s)
- Ariela Hoxha
- Internal Medicine Unit, Thrombotic and Hemorrhagic Center, Department of Medicine, University of Padua, Italy.
| | - Nicola Perin
- Internal Medicine Unit, Thrombotic and Hemorrhagic Center, Department of Medicine, University of Padua, Italy
| | - Marco Lovisotto
- Internal Medicine Unit, Thrombotic and Hemorrhagic Center, Department of Medicine, University of Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Simioni
- Internal Medicine Unit, Thrombotic and Hemorrhagic Center, Department of Medicine, University of Padua, Italy
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Ruffatti A, Tonello M, Calligaro A, Del Ross T, Favaro M, Zen M, Hoxha A, Alaibac M. Prevalence and adverse consequences of delayed diagnosis and misdiagnosis in thrombotic antiphospholipid syndrome. An observational cohort study and a review of the literature. Clin Rheumatol 2023; 42:3007-3019. [PMID: 37453028 PMCID: PMC10587197 DOI: 10.1007/s10067-023-06699-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
OBIECTIVES This study aims to prospectively evaluate the frequency and adverse consequences of diagnostic delay and misdiagnosis in a cohort of patients with thrombotic antiphospholipid syndrome (TAPS). In addition, a systematic review of the literature concerning the diagnostic delay and misdiagnosis of TAPS was carried out. METHODS Patient enrollment occurred between 1999 and 2022. The study group was formed by TAPS patients whose diagnosis was delayed and those who were misdiagnosed. The control group was made up of patients who were timely and correctly diagnosed with TAPS. RESULTS The literature review showed 42 misdiagnosed patients, 27 of them were in one retrospective cohort study and 15 in 13 case reports. One hundred sixty-one out of 189 patients (85.2%) received a timely, correct diagnosis of TAPS; 28 (14.8%) did not. The number of patients with diagnostic issues was significantly higher for the first period (1999-2010), and the number of patients with a correct diagnosis was significantly higher for the second one (2011-2022). When the clinical and laboratory characteristics of the patients with delayed diagnosis were compared with those with misdiagnosis, there was a significantly higher number of severe adverse consequences characterized by permanent disability or death in the latter group. The two most common types of misdiagnoses were systemic lupus erythematosus (6 cases, 46.1%) and cardiovascular diseases (4 cases, 30.8%). CONCLUSIONS The study demonstrates that although knowledge about TAPS has improved over time, diagnostic delays and errors remains to be addressed as they are strongly associated to adverse consequences. Key Points •Although knowledge of thrombotic antiphospholipid syndrome has improved over time, it is still limited. •Diagnostic delay and misdiagnosis are still an important issue that remains to be addressed as they are strongly associated to adverse consequences. •The three more frequent misdiagnoses are multiple sclerosis, systemic lupus erythematosus and cardiovascular diseases.
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Affiliation(s)
- Amelia Ruffatti
- Department of Medicine-DIMED, University Hospital of Padua, Padua, Italy.
| | - Marta Tonello
- Department of Medicine-DIMED, Rheumatology Unit, University Hospital of Padua, Padua, Italy
| | - Antonia Calligaro
- Department of Medicine-DIMED, Rheumatology Unit, University Hospital of Padua, Padua, Italy
| | - Teresa Del Ross
- Department of Medicine-DIMED, Rheumatology Unit, University Hospital of Padua, Padua, Italy
| | - Maria Favaro
- Department of Medicine-DIMED, Rheumatology Unit, University Hospital of Padua, Padua, Italy
| | - Margherita Zen
- Department of Medicine-DIMED, Rheumatology Unit, University Hospital of Padua, Padua, Italy
| | - Ariela Hoxha
- Department of Medicine-DIMED, General Internal Medicine Unit, Thrombotic and Hemorrhagic Disease Unit, University Hospital of Padua, Padua, Italy
| | - Mauro Alaibac
- Department of Medicine-DIMED, Dermatology Unit, University Hospital of Padua, Padua, Italy
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Zen M, Tonello M, Favaro M, Del Ross T, Calligaro A, Giollo A, Vesentini F, Gennaio IA, Arru F, Ruffatti A, Doria A. Antiphospholipid antibody carriers and patients with quiescent antiphospholipid syndrome show persistent subclinical complement activation. Rheumatology (Oxford) 2023:kead517. [PMID: 37774001 DOI: 10.1093/rheumatology/kead517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/20/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023] Open
Abstract
OBJECTIVES Complement activation has been advocated as one mechanism by which antiphospholipid antibodies (aPLs) can induce thrombosis. In patients with catastrophic aPL syndrome or re-thrombosis, enhanced complement activation was shown, even in quiescent phase of the disease. We aimed to assess complement activation and to investigate its association to clinical variables in aPL positive patients with a favorable disease course. METHODS Subjects with at least two consecutive positive aPL antibody results obtained ≥12 weeks apart were enrolled. They were subjects without history of thrombosis or pregnancy morbidity (aPL carriers), patients with pregnancy morbidity alone (OAPS), and/or with arterial, venous, or small-vessel thrombosis (TAPS); all patients should have been free of symptoms for ≥2 years. Patients affected with systemic autoimmune diseases were excluded. Healthy age and sex-matched subjects were included as controls. Plasma C5a and C5b-9 levels were assessed by commercially available ELISA assays. Non-parametric Mann-Whitney test and Spearman's correlation were applied. RESULTS Thirty-seven OAPS, 38 TAPS, 42 aPL carriers, and 30 healthy subjects were enrolled. Median C5a and C5b-9 levels were significantly higher in quiescent aPL positive patients (OAPS, TAPS, aPL carriers) compared with controls: C5a ng/ml 10.61 (IQR 6.87-15.46) vs 4.06 (2.66-7.35), p< 0.001; C5b-9 ng/ml 283.95 (175.8-439.40) vs 165.90 (124.23-236.8), p< 0.001. Similar C5a and C5b-9 levels were observed in OAPS and TAPS patients and aPL carriers. A positive correlation between C5b-9 median levels and the number of aPL positive tests was found (p= 0.002). CONCLUSIONS The persistence of aPL antibodies is associated to a persistent subclinical activation of the complement cascade.
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Affiliation(s)
- Margherita Zen
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Marta Tonello
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Maria Favaro
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Teresa Del Ross
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Antonia Calligaro
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Alessandro Giollo
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Filippo Vesentini
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Ilenia Anna Gennaio
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Federico Arru
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Amelia Ruffatti
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
| | - Andrea Doria
- University of Padua, Department of Medicine, Rheumatology Unit, Via Giustiniani 2, 35128 Padova Italy
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5
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Pengo V, Del Ross T, Tonello M, Andreoli L, Tincani A, Gresele P, Silvestri E, Simioni P, Campello E, Hoxha A, Falanga A, Ghirarduzzi A, Denas G. Impact of COVID-19 and COVID-19 vaccination on high-risk patients with Antiphospholipid Syndrome: a nationwide survey. Rheumatology (Oxford) 2022; 61:SI136-SI142. [PMID: 35412604 PMCID: PMC9047199 DOI: 10.1093/rheumatology/keac224] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/04/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives Patients with antiphospholipid syndrome (APS) and triple-positive for antiphospholipid antibodies (aPL) are at high-risk of recurrent events. As COVID-19 and COVID-19 vaccination may induce thrombotic complications, the objective of the study was to assess the course of COVID-19 and adverse events after vaccination in these patients. Methods This is a nationwide multicentre survey conducted in nine APS referral centres by means of a questionnaire. Included patients are thrombotic APS with triple-positive aPL confirmed 12 weeks apart. Reference specialist physicians used a four-graded scale of severity for COVID-19 [from 0 (asymptomatic) to 3 (hospitalization in intensive care unit)] and a six-graded scale for adverse reactions to vaccination [from 0 (transient local injection site sign/symptoms) to 5 (potentially life-threatening reactions)]. Outcomes were considered within a 30-days period. Results Out of 161 patients interviewed, 18 (11%) had COVID-19. All of them fully recovered without any progression to severe disease nor thromboembolic event. One-hundred-forty-six patients received the first (92%) and 129 (80%) the second dose of vaccine; side effects were minimal and, in most cases, (83% after the first and 68% after the second shot) limited to a sore arm. Fifteen patients (9%) were unvaccinated. Most of them raised doubts on the need for vaccination, complained for poor safety and in general were reluctant on COVID-19 vaccination. Conclusion Patients with triple-positive thrombotic APS did not suffer from severe COVID-19 outcomes. Importantly, COVID-19 vaccination was well tolerated. These data may reassure patients and physicians and contribute in reducing hesitancy in unvaccinated patients.
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Affiliation(s)
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia
| | - Paolo Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, General Internal Medicine, University of Padua
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, General Internal Medicine, University of Padua
| | - Ariela Hoxha
- Internal Medicine Unit, Department of Medicine, San Bortolo Hospital, Vicenza
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine and Haemostasis and Thrombosis Centre, Hospital Papa Giovanni XXIII, Bergamo
| | - Angelo Ghirarduzzi
- SOC Medicina, Medicina Cardiovascolare, Dipartimento di Medicina Interna-AUSL-IRCCS Reggio Emilia, Italy, all in
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6
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Lorenzin M, Ughi N, Ariani A, Raffeiner B, Frallonardo P, Hoxha A, Ortolan A, Favero M, Parisi S, Bortoluzzi A, Ceccarelli F, Lucchetti R, Furini F, Del Ross T, Zanetti A, Carrara G, Scirè CA, Doria A, Ramonda R. Predictors of disease activity in gout: a 12-month analysis of the ATTACk (Achieving improvement in the management of crystal-induced arthritis) multicentre cohort study. Clin Exp Rheumatol 2022; 41:628-633. [PMID: 35930471 DOI: 10.55563/clinexprheumatol/eh0jcp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Gout treatment is largely suboptimal in clinical practice. We aimed to assess the predictors of disease-activity at 12 months in a real-life setting. METHODS Consecutive patients referred to Rheumatology Units for suspected acute crystal-induced arthritis were enrolled in a multicentre-cohort study. Only patients with clinical diagnosis of gout were eligible. Disease-activity was evaluated by the Patient Acceptable Symptom State (PASS) on a visual analogue scale (VAS, 0=unsatisfactory, 100=satisfactory) at 0 (T0) and 12 months (T12), and the composite score called Gout Activity Score (GAS) calculated on the number of arthritic attacks (flare count), serum uric acid (sUA), cumulative number of tophi, VAS (T12), PtGA (T12). Multivariate linear regression model was performed to assess predictors of gout disease-activity at T12 with PASS and GAS as outcomes. RESULTS 201 patients had gout (diagnosis on synovial fluid in 45%, tophi in 26%, mean sUA 7.4±1.9 mg/L, 85% with urate-lowering therapy (ULT) in progress/initiated at T0); mean age 63±13 years, 88% men, median (interquartile range) disease duration 2.9 years (0.7-9.4). Follow-up visits were performed in 113 (56%) patients at T12. Mean PASS observed at T0 and at T12 were 38±27 and 74±23, respectively, whereas GAS at T12 was 10±8. A significant association was observed between the presence of tophi and PASS at T12 (-15.3, 95% CI -25.5, -5.2; p=0.003) and GAS at T12 (+4.0, 95% CI 0.6,7.4; p=0.02), adjusted for age, sex, disease duration, sUA <6 mg/dL, tender joint count, PASS at T0, ULT). CONCLUSIONS The baseline presence of tophi may predict high disease-activity at T12, thus worsening GAS and patients' pain perception.
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Affiliation(s)
- Mariagrazia Lorenzin
- University of Padova, Department of Medicine-DIMED, Rheumatology Unit, Padova, Italy
| | - Nicola Ughi
- Rheumatology Division, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Alarico Ariani
- Department of Medicine, Internal Medicine and Rheumatology Unit, Azienda Ospedaliera Universitaria di Parma, Parma, Italy
| | | | - Paola Frallonardo
- University of Padova, Department of Medicine-DIMED, Rheumatology Unit, Padova, Italy; UO Medicina Generale, Ospedale Riabilitativo di Alta Specialità - ORAS- Motta di Livenza, Treviso, Italy
| | - Ariela Hoxha
- University of Padova, Department of Medicine-DIMED, Rheumatology Unit, Padova, Italy; Internal Medicine Unit, Department of Medicine, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Augusta Ortolan
- University of Padova, Department of Medicine-DIMED, Rheumatology Unit, Padova, Italy
| | - Marta Favero
- University of Padova, Department of Medicine-DIMED, Rheumatology Unit, Padova, Italy; Internal Medicine 1, Ca' Foncello Hospital, ULSS2 Marca Trevigiana, Treviso, Italy
| | - Simone Parisi
- SC Reumatologia, AOU Città della Salute e della Scienza, Torino, Italy
| | - Alessandra Bortoluzzi
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona, Ferrara, Italy
| | - Fulvia Ceccarelli
- Lupus Clinic, Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza University of Rome, Rome, Italy
| | - Ramona Lucchetti
- Lupus Clinic, Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza University of Rome, Rome, Italy
| | - Federica Furini
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona, Ferrara, Italy
| | - Teresa Del Ross
- University of Padova, Department of Medicine-DIMED, Rheumatology Unit, Padova, Italy
| | - Anna Zanetti
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy; Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Carlo Alberto Scirè
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona, Ferrara, Italy; Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Andrea Doria
- University of Padova, Department of Medicine-DIMED, Rheumatology Unit, Padova, Italy
| | - Roberta Ramonda
- University of Padova, Department of Medicine-DIMED, Rheumatology Unit, Padova, Italy.
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7
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Ruffatti A, Tonello M, Calligaro A, Del Ross T, Favaro M, Zen M, Carletto A, Lotti V, Bertoldo E, Tedesco F, Hoxha A, Biasi D. High plasma C5a and C5b-9 levels during quiescent phases are associated to severe antiphospholipid syndrome subsets. Clin Exp Rheumatol 2021; 40:2088-2096. [DOI: 10.55563/clinexprheumatol/7cinzu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Amelia Ruffatti
- Department of Medicine, University Hospital of Padova, Italy.
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University Hospital of Padova, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padova, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padova, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padova, Italy
| | - Margherita Zen
- Rheumatology Unit, Department of Medicine, University Hospital of Padova, Italy
| | - Antonio Carletto
- Department of Medicine, Rheumatology Unit, L.U.R.M. University Hospital of Verona, Italy
| | - Virginia Lotti
- Department of Medicine, Rheumatology Unit, L.U.R.M. University Hospital of Verona, Italy
| | - Eugenia Bertoldo
- Department of Medicine, Rheumatology Unit, L.U.R.M. University Hospital of Verona, Italy
| | - Francesco Tedesco
- Istituto Auxologico Italiano, IRCCS, Laboratory of Immuno-Rheumatology, Milan, Italy
| | - Ariela Hoxha
- Department of Medicine, Internal Medicine Unit, San Bortolo Hospital, Vicenza, Italy
| | - Domenico Biasi
- Department of Medicine, Rheumatology Unit, L.U.R.M. University Hospital of Verona, Italy
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8
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Ruffatti A, Tonello M, Favaro M, Del Ross T, Calligaro A, Ruffatti AT, Gervasi MT, Hoxha A. The efficacy and safety of second-line treatments of refractory and/or high risk pregnant antiphospholipid syndrome patients. A systematic literature review analyzing 313 pregnancies. Semin Arthritis Rheum 2020; 51:28-35. [PMID: 33360227 DOI: 10.1016/j.semarthrit.2020.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/23/2020] [Accepted: 10/16/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The most efficacious strategy to manage pregnant patients with antiphospholipid syndrome (APS) refractory to conventional heparin/low-dose aspirin treatment or at high risk of adverse pregnancy outcomes has not been determined with any degree of certainty. The study set out to evaluate the efficacy and safety of the second-line treatments most frequently used in addition to conventional therapy, and the data were analyzed to identify which is/are associated to the best pregnancy outcomes. METHODS A systematic review of the literature on studies concerning second-line treatments for refractory and/or high risk pregnant APS women published between February 2006 and February 2020 was conducted. The records were retrieved by searching Medline via Pubmed, the Web of Science platform, the Cochrane library database and clinicaltrials.gov. RESULTS Fourteen studies met the eligibility criteria of the review: six retrospective cohort studies, one case-control, one case-series and six case reports. The results of single treatment protocols based upon hydroxychloroquine (HCQ), low-dose steroids (LDS), intravenous immunoglobulins (IVIG), plasma exchange (PE) or pravastatin and of combination protocols based upon HCQ+LDS, IVIG+LDS, PE+LDS and PE+IVIG used during 313 pregnancies in 303 APS women were analyzed and compared. The second-line treatments produced 261/313 (83.4%) live births; severe pregnancy complications were registered in 75/313 (24%) pregnancies. Drug side-effects were observed in 3/313 (0.9%) pregnancies. Statistical analysis identified a significantly higher live birth rate and/or a significantly lower number of severe complications in the pregnancies treated with IVIG, HCQ, pravastatin, PE+IVIG and PE+LDS. CONCLUSION Our results suggest using low-dose IVIG (< 2 g/Kg/month) or HCQ 400 mg/day starting before pregnancy in women with APS refractory to conventional therapy, while high-dose IVIG (2 g/Kg/month) associated with PE or alone in those with high risk±refractory APS.
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy.
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy
| | - Alessandra Teresa Ruffatti
- Gynaecology and Obstetrics Unit, Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Maria Teresa Gervasi
- Gynaecology and Obstetrics Unit, Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua Italy; Internal Medicine Unit, Department of Medicine, San Bortolo Hospital, Vicenza, Italy
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9
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Tonello M, Calligaro A, Favaro M, Del Ross T, Veronese P, Salvan E, Gervasi MT, Ruffatti A. The first thrombotic event in purely obstetric antiphospholipid syndrome patients and in antiphospholipid antibody carriers: comparison of incidence and characteristics. Arch Gynecol Obstet 2020; 303:455-461. [PMID: 32880711 DOI: 10.1007/s00404-020-05766-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/24/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The long-term risk of thrombosis after pregnancy in women with purely obstetric antiphospholipid syndrome (OAPS) is not well defined. The current study's primary outcome was to evaluate the incidence and characteristics of the first thrombotic event in OAPS, identifying the risk factors for thrombosis in OAPS was its secondary one. METHODS Patients with purely OAPS were consecutively enrolled between September 1999 and September 2019. Subjects without a history of pregnancy morbidity or thrombosis but with persistent positivity for one or more antiphospholipid antibodies (aPL carriers) made up the control group. The study groups included 94 OAPS patients and 124 aPL carriers who were matched for clinical and laboratory parameters. RESULTS An event rate of 0.49/100 patient years was registered in OAPS patients during a mean follow-up of 8.7 years ± 5.5 SD. Kaplan-Meier survival analysis revealed that the cumulative incidence of thromboembolic events was not significantly different in OAPS patients vs aPL carriers. Arterial thrombosis and cerebrovascular events were the more frequent types of vascular involvement in the two groups. As far as risk factors for thrombosis were concerned, the presence of lupus anticoagulant significantly prevailed in both thrombotic OAPS patients and thrombotic aPL carriers with respect to purely OAPS patients and aPL carriers who did not develop thrombosis (p = 0.01 and p = 0.00, respectively). CONCLUSION Just as for aPL carriers, closer monitoring and possibly, a pharmacological prophylaxis should be reserved for OAPS patients at highest risk of developing the first thrombotic event.
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Affiliation(s)
- Marta Tonello
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Paola Veronese
- Obstetrics and Gynecology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Elisa Salvan
- General Department, University of Padua, Padua, Italy
| | - Maria Teresa Gervasi
- Obstetrics and Gynecology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy.
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10
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Hoxha A, Favaro M, Calligaro A, Del Ross T, Ruffatti AT, Infantolino C, Tonello M, Mattia E, Ruffatti A. Upgrading Therapy Strategy Improves Pregnancy Outcome in Antiphospholipid Syndrome: A Cohort Management Study. Thromb Haemost 2019; 120:36-43. [PMID: 31634958 DOI: 10.1055/s-0039-1697665] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The current study evaluates the efficacy and safety of different treatment strategies for pregnant patients with antiphospholipid syndrome. One hundred twenty-seven consecutive pregnancies were assessed; 87 (68.5%) with a history of pregnancy morbidity alone were treated with prophylactic low molecular weight heparin (LMWH) + low-dose aspirin (LDA, 100 mg) (group I) and 40 (31.5%) with a history of thrombosis and/or severe pregnancy complications with therapeutic LMWH + LDA (group II). LMWH doses were increased throughout the pregnancies depending on the patients' weight gain, and treatment was switched to a more intensive one at the first sign of maternal/fetal complications. The study's primary outcome was live births. There were no significant differences in live birth rate between group I (95.4%) and group II (87.5%). Even fetal complication rate was similar in the two groups; group II nevertheless had a higher prevalence of maternal and neonatal complications (p = 0.0005 and p = 0.01, respectively) and registered a significantly lower gestational age at delivery and birth weight (p = 0.0001 and p = 0.0005, respectively). Two patients in group I switched to group II therapy, six patients in group II switched to a more intensive treatment strategy (weekly plasma exchange + fortnightly intravenous immunoglobulins in addition to therapeutic LMWH + LDA). The multivariate analysis uncovered that triple antiphospholipid antibodies positivity was an independent factor leading to a more intensive therapy. All eight switched patients achieved a live birth. Study results revealed that adjusted LMWH doses and switching therapy at first signs of severe pregnancy complications led to a high rate of live births in antiphospholipid syndrome patients.
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Affiliation(s)
- Ariela Hoxha
- Department of Medicine-DIMED, Rheumatology Unit, University of Padua, Padua, Italy.,Department of Medicine, Internal Medicine Unit, San Bortolo Hospital, Vicenza, Italy
| | - Maria Favaro
- Department of Medicine-DIMED, Rheumatology Unit, University of Padua, Padua, Italy
| | - Antonia Calligaro
- Department of Medicine-DIMED, Rheumatology Unit, University of Padua, Padua, Italy
| | - Teresa Del Ross
- Department of Medicine-DIMED, Rheumatology Unit, University of Padua, Padua, Italy
| | | | - Chiara Infantolino
- Obstetrics and Gynaecology Unit, University Hospital Padua, Padua, Italy
| | - Marta Tonello
- Department of Medicine-DIMED, Rheumatology Unit, University of Padua, Padua, Italy
| | - Elena Mattia
- Department of Medicine-DIMED, Rheumatology Unit, University of Padua, Padua, Italy
| | - Amelia Ruffatti
- Department of Medicine-DIMED, Rheumatology Unit, University of Padua, Padua, Italy
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11
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Lazzaroni MG, Fredi M, Andreoli L, Chighizola CB, Del Ross T, Gerosa M, Kuzenko A, Raimondo MG, Lojacono A, Ramazzotto F, Zatti S, Trespidi L, Meroni PL, Pengo V, Ruffatti A, Tincani A. Triple Antiphospholipid (aPL) Antibodies Positivity Is Associated With Pregnancy Complications in aPL Carriers: A Multicenter Study on 62 Pregnancies. Front Immunol 2019; 10:1948. [PMID: 31475009 PMCID: PMC6702797 DOI: 10.3389/fimmu.2019.01948] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/01/2019] [Indexed: 01/20/2023] Open
Abstract
Objective: Antiphospholipid antibodies (aPL) are risk factors for thrombosis and adverse pregnancy outcomes (APO). The management of the so called “aPL carriers” (subjects with aPL positivity without the clinical criteria manifestations of APS) is still undefined. This study aims at retrospectively evaluating the outcomes and the factors associated with APO and maternal complications in 62 pregnant aPL carriers. Methods: Medical records of pregnant women regularly attending the Pregnancy Clinic of 3 Rheumatology centers from January 1994 to December 2015 were retrospectively evaluated. Patients with concomitant autoimmune diseases or other causes of pregnancy complications were excluded. Results: An aPL-related event was recorded in 8 out of 62 patients (12.9%) during pregnancy: 2 thrombosis and 6 APO. At univariate analysis, factors associated with pregnancy complications were acquired risk factors (p:0.008), non-criteria aPL manifestations (p:0.024), lupus-like manifestations (p:0.013), and triple positive aPL profile (p:0.001). At multivariate analysis, only the association with a triple aPL profile was confirmed (p:0.01, OR 21.3, CI 95% 1.84–247). Patients with triple aPL positivity had a higher rate of pregnancy complications, despite they were more frequently receiving combined treatment of low dose aspirin (LDA) and low molecular weight heparin (LMWH) at prophylactic dose. Conclusion: This study highlights the importance of risk stratification in pregnant aPL carriers, in terms of both immunologic and non-immunologic features. Combination treatment with LDA and LMWH did not prevent APO in some cases, especially in carriers of triple aPL positivity. Triple positive aPL carriers may deserve additional therapeutic strategies during pregnancy.
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Affiliation(s)
- Maria-Grazia Lazzaroni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Micaela Fredi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Cecilia Beatrice Chighizola
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy.,Rheumatology Unit, Istituto Auxologico Italiano, Milan, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Pini-CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Kuzenko
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Maria-Gabriella Raimondo
- Division of Clinical Rheumatology, ASST Pini-CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Andrea Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Obstetrics and Gynaecology Unit, ASST Spedali Civili, Brescia, Italy
| | | | - Sonia Zatti
- Obstetrics and Gynaecology Unit, ASST Spedali Civili, Brescia, Italy
| | - Laura Trespidi
- Obstetrics and Gynaecology Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier-Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac Thoracic and Vascular Sciences, Thrombosis Centre, University of Padova, Padova, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy.,I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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12
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Tonello M, Mattia E, Favaro M, Del Ross T, Calligaro A, Salvan E, Hoxha A, Fedrigo M, Ruffatti A. IgG phosphatidylserine/prothrombin antibodies as a risk factor of thrombosis in antiphospholipid antibody carriers. Thromb Res 2019; 177:157-160. [DOI: 10.1016/j.thromres.2019.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/28/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
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13
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Larosa M, Del Ross T, Calligaro A, Favaro M, Zanatta E, Iaccarino L, Doria A. Clinical outcomes and predictors of maternal and fetal complications in pregnancies of patients with systemic lupus erythematosus. Expert Rev Clin Immunol 2019; 15:617-627. [PMID: 30933534 DOI: 10.1080/1744666x.2019.1601557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Systemic Lupus Erythematosus (SLE) mostly affects women during their childbearing years. Fertility is preserved in SLE patients, but pregnancy is often characterized by a high number of maternal and fetal complications. Adverse pregnancy outcomes (APO) have been widely studied over the last decades and several investigators have focused on the potential clinical and serological predictors of maternal and fetal complications. Areas covered: In this review, we analyzed maternal and fetal complications in SLE patients and predictors of APO. Active disease in the 6 months before conception, lupus nephritis, anti-phospholipid (aPL), anti-SSA/Ro and/or anti-SSB/La antibodies have been identified as the most consistent predictors of maternal and fetal complications to date. However, molecular mechanisms and underlying immunological pathways involved in APO still remain elusive. Expert opinion: Difficulties in assessing prevalence and predictors of APO in SLE patients are due to lack of uniformity in the definitions and methods used in the different studies. In addition, some maternal and fetal complications are difficult to diagnose and to differentiate from each other. Preconception counseling is paramount to prevent APO, and it should consider four main factors: disease activity/lupus nephritis, safety of drugs, aPL, anti-SSA/Ro, and/or anti-SSB/La antibodies.
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Affiliation(s)
- Maddalena Larosa
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Teresa Del Ross
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Antonia Calligaro
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Maria Favaro
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Elisabetta Zanatta
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Luca Iaccarino
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Andrea Doria
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Alessandra Zambon
- Obstetrics and Gynecology Unit, Department of Woman’s and Child’s Health, University Hospital of Padua, Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
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Ruffatti A, De Silvestro G, Marson P, Tonello M, Calligaro A, Favaro M, Del Ross T, Hoxha A, Mattia E, Pengo V. Catastrophic antiphospholipid syndrome: Lessons from 14 cases successfully treated in a single center. A narrative report. J Autoimmun 2018; 93:124-130. [DOI: 10.1016/j.jaut.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/30/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022]
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Mattia E, Hoxha A, Tonello M, Favaro M, Del Ross T, Calligaro A, Ghirardello A, Ruffatti A. Detection of autoantibodies to the p200-epitope of SSA/Ro52 antigen. A comparison of two laboratory assays. ACTA ACUST UNITED AC 2018; 56:927-932. [DOI: 10.1515/cclm-2017-0704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 11/22/2017] [Indexed: 12/11/2022]
Abstract
Abstract
Background:
Anti-p200 antibodies have been receiving growing interest in view of findings associating their presence to risk of fetal autoimmune congenital heart block (CHB). The study compares and evaluates the performance of two assays currently being used for their detection.
Methods:
One hundred and sixteen pregnant women positive for anti-SSA/Ro52 antibodies were considered as the study population. Fifty women negative for anti-SSA/Ro52 antibodies were considered as the control population. Anti-p200 antibodies were analyzed using two home-made ELISA assays: one with biotinylated antigen and the other with free antigen.
Results:
The specificity of the p200-free assay was significantly higher with respect to that of the p200-biotin assay (p=0.023). Both methods showed a high area under curve (AUC), thus, a good accuracy. There was a significant prevalence of anti-p200 antibodies when the p200-free assay was used to analyze the sera of the pregnant women with CHB fetuses (p=0.007). Cohen’s κ and Spearman’s ρ coefficients showed a good concordance (0.71) and a high correlation (0.93), respectively.
Conclusions:
The p200-free assay with respect to the biotin-based method was more specific in detecting p200 antibodies in women positive for anti-SSA/Ro52 antibodies. In addition, only the p200-free method significantly found p200 antibodies in patients with fetal CHB.
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Affiliation(s)
- Elena Mattia
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Ariela Hoxha
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Marta Tonello
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Maria Favaro
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Teresa Del Ross
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Antonia Calligaro
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Anna Ghirardello
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Amelia Ruffatti
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
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Ruffatti A, Tonello M, Del Ross T, Cavazzana A, Grava C, Noventa F, Tona F, Iliceto S, Pengo V. Antibody profile and clinical course in primary antiphospholipid syndrome with pregnancy morbidity. Thromb Haemost 2017; 96:337-41. [PMID: 16953276 DOI: 10.1160/th06-05-0287] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryIn women diagnosed as having category I primary obstetric antiphospholipid syndrome, clinical characteristics and the risk of subsequent thromboembolic events and further unsuccessful pregnancy has not been clearly documented. Women with unexplained obstetric complications and no definite autoimmune systemic diseases were tested for lupus anticoagulant (LA), IgG/ IgM anticardiolipin (aCL) and IgG/IgM anti-human β2-Glycoprotein I (aβ2GPI) antibodies and diagnosed as having primary antiphospholipid syndrome (APS) in classification category I on the basis of more than one laboratory criteria present in any combination. Characteristics at the time of diagnosis and risk factors for subsequent clinical events during a mean follow-up of 6.3 years were evaluated. Fifty-three of 600 women studied were found to fulfil obstetric criteria and had more than one positive laboratory test at the time of diagnosis. All the women were a CL and aβ2GPI positive, and 16 were also LA positive. This latter group (triple positivity) had distinct features and had more frequently experienced previous thromboembolism (OR= 122.5, 95% CI 16–957, p<0.001).They also had an increased rate of late pregnancy loss (OR=16.2, 95%CI 0.9–292, p=0.01), and a higher IgG aβ2GPI titer at diagnosis (median, 25th and 75th percentile were 118, 37–962, vs. 23, 18–32, respectively, p<0.0001). During follow-up, the rate of thromboembolic events was significantly higher in the group of women with triple positivity and/ or previous thromboembolism (OR=57.5, 95% CI 2.7–1160, p=0.0004) which were the only independent predictors of TE in the multivariate model. Recurrent pregnancy loss took place in seven out of 47 women who had a new pregnancy. Triple positivity and/or previous thromboembolism were again the only independent markers (OR=34.4, 95% CI 3.5–335.1, p=0.003) of an unsuccessful new pregnancy. In conclusion, in primary APS with pregnancy morbidity in classification category I, quite different groups of patients may be identified on the basis of laboratory tests. Triple positivity and/or a history of thromboembolism predict new TE events and new unsuccessful pregnancies.
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Affiliation(s)
- Amelia Ruffatti
- Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Padua, Italy
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Hoxha A, Calligaro A, Di Poi E, Peccatori S, Favaro M, Del Ross T, Ramonda R, Grava C, Raffeiner B, Ravagni P, De Vita S, Ruffatti A. Pregnancy and foetal outcomes following anti-tumor necrosis factor alpha therapy: A prospective multicentre study. Joint Bone Spine 2017; 84:169-173. [DOI: 10.1016/j.jbspin.2016.03.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/24/2016] [Indexed: 02/07/2023]
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Del Ross T, Ruffatti A, Floreani A, Hoxha A, Punzi L. The efficacy of adalimumab in psoriatic arthritis concomitant to overlapping primary biliary cholangitis and primary sclerosing cholangitis: a case report. BMC Musculoskelet Disord 2016; 17:485. [PMID: 27876037 PMCID: PMC5120445 DOI: 10.1186/s12891-016-1335-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/09/2016] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The overlap syndrome of primary biliary cholangitis (formerly called primary biliary cirrhosis) and primary sclerosing cholangitis is an extremely rare condition that has never been described in association with other immune-mediated diseases, including psoriatic arthritis. While treatment with anti-Tumour Necrosis Factor-alpha (TNF-α) agents has proved to be effective in inflammatory arthropathies such as psoriatic arthritis, they have been employed in only a limited number of patients with autoimmune hepatitis, and their effectiveness is unclear. CASE PRESENTATION We report the case of a 51-year-old female affected with psoriatic arthritis concomitant to overlapping primary biliary cholangitis and primary sclerosing cholangitis in whom 28 months of adalimumab treatment improved the symptoms of the inflammatory arthropathy as well as those of both cholangiopathies. CONCLUSION Our results suggest that further studies examining the therapeutic role of this particular TNF-α blocker are warranted in cholestatic autoimmune hepatitis patients, and in particular in those individuals in whom the disease is associated with inflammatory arthropathies.
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Affiliation(s)
- Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy.
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Leonardo Punzi
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
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Ruffatti A, Cerutti A, Favaro M, Del Ross T, Calligaro A, Hoxha A, Marson P, Leoni L, Milanesi O. Plasmapheresis, intravenous immunoglobulins and bethametasone - a combined protocol to treat autoimmune congenital heart block: a prospective cohort study. Clin Exp Rheumatol 2016; 34:706-713. [PMID: 27385463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 02/08/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES At the moment there are no standard guidelines for the treatment of autoimmune congenital heart block (CHB). We set out to carry out a prospective cohort study to evaluate the benefits, limits, and safety of a combined therapy protocol to treat antibody-related CHB. METHODS Twelve consecutive pregnant patients positive to anti-SSA/Ro ± anti-SSB/La antibodies in whom CHB was detected were prospectively evaluated from 2009 to 2014. The treatment protocol consisted of: weekly plasmapheresis, fortnightly intravenous immunoglobulins (IVIG), and daily 4 mg betamethasone from CHB detection until delivery; IVIG was administered to the neonates soon after birth. RESULTS At the time CHB was detected, six of the foetuses presented atrioventricular blocks of 2(nd) degree type and six of 3(rd) degree type. Two of the foetuses with a 2(nd) degree block reverted to a 1st degree block and one to a normal atrioventricular conduction. The condition was stable throughout the pregnancy in the other three cases of 2(nd) degree block. All six 3(rd) degree blocks were stable during pregnancy and confirmed at birth. After a mean of 37.6 months ± 19.6 SD post-birth, the infants with 1st, normal sinus rhythm, and 2(nd) degree blocks at birth were all found to be stable. During the follow-up (29 months ± 19.8 SD), pacemakers were implanted in three of the six infants with 3(rd) degree blocks. CONCLUSIONS This combined therapy seems to be effective and safe in treating 2(nd) degree CHB, while its efficacy in treating 3rd degree CHB remains to be established.
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Italy.
| | - Alessia Cerutti
- Paediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - Piero Marson
- Apheresis Unit, Blood Transfusion Service, University Hospital of Padua, Italy
| | - Loira Leoni
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Ornella Milanesi
- Paediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Italy
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Tonello M, Ruffatti A, Favaro M, Tison T, Del Ross T, Calligaro A, Hoxha A, Mattia E, Punzi L. Maternal autoantibody profiles at risk for autoimmune congenital heart block: a prospective study in high-risk patients. Lupus Sci Med 2016; 3:e000129. [PMID: 27026811 PMCID: PMC4809148 DOI: 10.1136/lupus-2015-000129] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 02/15/2016] [Accepted: 03/05/2016] [Indexed: 11/17/2022]
Abstract
Objective This prospective study aimed to identify antibody profiles characterising mothers with fetuses developing congenital heart block (CHB) by comparing their antibody frequencies and levels with those in unaffected mothers. Methods Eighty-one consecutive pregnant patients positive to anti-Ro±anti-La antibodies, at high risk of developing fetal CHB were prospectively studied. The 16 patients with fetal CHB outcome were considered the study population and the 65 patients with normal pregnancy outcomes were considered the control cohort. Anti-Ro52, anti-Ro60, anti-p200 and anti-La antibodies were assayed using home-made ELISA assays. Results The prevalence of anti-p200 antibodies was significantly higher in the fetal CHB affected patients than in the controls (p=0.03). Combinations of anti-p200 with anti-Ro52 and anti-Ro60 antibodies were significantly more frequent in the women with fetuses developing CHB than in the controls (p=0.03 for all combinations). The women with fetal CHB had significantly higher mean anti-Ro52, anti-Ro60 and anti-p200 levels than the controls (p=0.003, p=0.0001 and p=0.04, respectively); mean anti-La/SSB level was not significantly different in the two cohorts (p=0.25). Conclusions Since anti-p200, anti-Ro52 and anti-Ro60 antibodies, especially at high level, seem to identify patients at increased risk of developing fetal CHB, their detection could recognise anti-Ro/La positive women at risk for having an infant with this rare, potentially dangerous disorder.
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Affiliation(s)
- Marta Tonello
- Rheumatology Unit, Department of Medicine , University of Padua , Padua , Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine , University of Padua , Padua , Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine , University of Padua , Padua , Italy
| | - Tiziana Tison
- Blood Transfusion Unit , University Hospital of Padua , Padua , Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine , University of Padua , Padua , Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine , University of Padua , Padua , Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine , University of Padua , Padua , Italy
| | - Elena Mattia
- Rheumatology Unit, Department of Medicine , University of Padua , Padua , Italy
| | - Leonardo Punzi
- Rheumatology Unit, Department of Medicine , University of Padua , Padua , Italy
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Hoxha A, Calligaro A, Tonello M, Ramonda R, Carletto A, Paolazzi G, Bortolotti R, Del Ross T, Grava C, Boaretto M, Favaro M, Teghil V, Ruffatti A, Punzi L. The clinical relevance of early anti-adalimumab antibodies detection in rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis: A prospective multicentre study. Joint Bone Spine 2015; 83:167-71. [PMID: 26750762 DOI: 10.1016/j.jbspin.2015.04.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 04/15/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To evaluate the relevance of anti-adalimumab (anti-ADA) antibodies (Abs) and their relationship with clinical/laboratory features in rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA). METHODS Fifty-eight patients affected with RA, AS and PsA were prospectively enrolled. Clinical/laboratory characteristics, disease activity, anti-ADA, anti-nuclear (ANA), anti-double strand (ds)DNA, anti-extractable nuclear antigens (anti-ENA) and anti-phospholipid Abs (aPL) were evaluated at baseline, 4, 12 and 24 weeks of adalimumab treatment. RESULTS Anti-ADA Abs were observed in 11/58 (19%) patients; they were detected within the 4th week of therapy in 90.9% of the positive subjects. Anti-ADA positivity was associated with significantly lower mean adalimumab serum levels (P<0.05). Treatment failure was observed in 20/58 (34.5%) patients and was significantly associated with anti-ADA Abs (P<0.05). Mean adalimumab serum levels were significantly lower in patients with treatment failure than in the responders one, both in the whole cohort (P<0.01) and in the group of anti-ADA positive patients (P<0.01). Adverse events happened more often in anti-ADA positive then in anti-ADA negative patients (27.3% vs 14.9%). CONCLUSIONS Anti-ADA abs could be considered an early marker associated to a poor clinical response to adalimumab treatment. Routine ANA/anti-ENA/aPL monitoring did not reveal as useful tools to predict the development of anti-ADA abs.
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Affiliation(s)
- Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy.
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy
| | - Antonio Carletto
- Rheumatology Unit, Department of Medicine, University of Verona, Piazzale L.A. Scuro 10, 37134 Verona, Italy
| | - Giuseppe Paolazzi
- Rheumatology Unit, S. Chiara Hospital, Largo Medaglie D'oro, 9, 38122 Trento, Italy
| | - Roberto Bortolotti
- Rheumatology Unit, S. Chiara Hospital, Largo Medaglie D'oro, 9, 38122 Trento, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy
| | - Chiara Grava
- Department of Medicine, S. Martino Hospital, Viale Europa, 22, 32100 Belluno, Italy
| | - Massimo Boaretto
- Department of Medicine, S. Martino Hospital, Viale Europa, 22, 32100 Belluno, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy
| | - Vera Teghil
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy
| | - Leonardo Punzi
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani, 2-35128 Padova, Italy
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Ruffatti A, Favaro M, Brucato A, Ramoni V, Facchinetti M, Tonello M, Del Ross T, Calligaro A, Hoxha A, Grava C, De Silvestro G. Apheresis in high risk antiphospholipid syndrome pregnancy and autoimmune congenital heart block. Transfus Apher Sci 2015; 53:269-78. [DOI: 10.1016/j.transci.2015.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ruffatti A, Salvan E, Del Ross T, Gerosa M, Andreoli L, Maina A, Alijotas-Reig J, De Carolis S, Mekinian A, Bertero MT, Canti V, Brucato A, Bremme K, Ramoni V, Mosca M, Di Poi E, Caramaschi P, Galeazzi M, Tincani A, Trespidi L, Meroni PL. Treatment strategies and pregnancy outcomes in antiphospholipid syndrome patients with thrombosis and triple antiphospholipid positivity. A European multicentre retrospective study. Thromb Haemost 2014; 112:727-35. [PMID: 25008944 DOI: 10.1160/th14-03-0191] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 05/08/2014] [Indexed: 12/15/2022]
Abstract
Previous thrombosis, diagnosis of systemic lupus erythematosus (SLE) and triple antiphospholipid (aPL) antibody positivity have recently been found to be independent factors associated to pregnancy failure during conventional therapy in women with antiphospholipid syndrome (APS). This study aimed to assess the effect of various treatment strategies on pregnancy outcomes in women with APS and the risk factors for pregnancy failure. One hundred ninety-six pregnancies of 156 patients diagnosed with APS were analysed: 118 (60.2%) of these had previous thrombosis, 81 (41.3%) were diagnosed with SLE, and 107 (54.6%) had triple aPL positivity. One hundred seventy-five (89.3%) were treated with conventional therapies (low-dose aspirin [LDA] or prophylactic doses of heparin + LDA or therapeutic doses of heparin + LDA), while 21 (10.7%) were prescribed other treatments in addition to conventional therapy. The pregnancies were classified into seven risk profiles depending on the patients' risk factors - thrombosis, SLE, and triple aPL positivity - and their single, double or triple combinations. It was possible to find significant difference in outcomes correlated to treatments only in the thrombosis plus triple aPL positivity subset, and logistic regression analysis showed that additional treatments were the only independent factor associated to a favourable pregnancy outcome (odds ratio=9.7, 95% confidence interval=1.1-88.9, p-value<0.05). On the basis of this retrospective study, we found that APS pregnant patients with thrombosis and triple aPL positivity treated with additional therapy had a significant higher live-birth rate with respect to those receiving conventional therapy alone.
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Affiliation(s)
- Amelia Ruffatti
- Amelia Ruffatti, Reumatologia, Policlinico Universitario, Via Giustiniani, 2 - 35128 Padova, Italy, Tel.: +039 049 8212192, Fax: +039 049 8212191, E-mail:
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Del Ross T, Ruffatti A, Visentin MS, Tonello M, Calligaro A, Favaro M, Hoxha A, Punzi L. Treatment of 139 pregnancies in antiphospholipid-positive women not fulfilling criteria for antiphospholipid syndrome: a retrospective study. J Rheumatol 2013; 40:425-9. [PMID: 23418380 DOI: 10.3899/jrheum.120576] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The effect of low-dose aspirin (LDA) on pregnancy outcome in antiphospholipid (aPL)-positive women not fulfilling the criteria for antiphospholipid antibody syndrome (APS) was evaluated retrospectively. METHODS We evaluated 139 pregnancies of 114 aPL-positive women not fulfilling the Sydney classification criteria for definite APS (104 treated with LDA, 35 untreated). Inclusion criteria consisted of (1) any titer of aPL and no previous pregnancy or no pregnancy losses (defined as aPL carriers); (2) any titer of aPL and 1 or 2 pregnancy losses before the 10th gestational week. No women had previous thrombosis. The rate of pregnancy loss, gestational age at delivery, and birth weight percentile were compared in the treated and untreated patients. Associations between clinical and laboratory characteristics and pregnancy outcomes were investigated. RESULTS The rate of pregnancy loss was low in both treated and untreated groups (7.7% vs 2.9%, respectively). There were no statistically significant differences in the rate of pregnancy loss, gestational age at birth, or birth weight percentile in the treated and untreated groups. There were significant associations between gestational age at birth ≤ 34th week and positivity for lupus anticoagulant (p = 0.025) and anti-ß2-glycoprotein I IgG antibodies at titers > 99th (p = 0.016). CONCLUSION LDA treatment does not appear to improve pregnancy outcome in low-risk women not fulfilling the criteria for APS. Because antibody profile seems to influence pregnancy outcome, further studies of patients stratified according to their antibody profile are warranted.
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Affiliation(s)
- Teresa Del Ross
- Rheumatology Unit, Department of Medicine - DIMED, University of Padua, Padua, Italy.
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Ramonda R, Del Ross T, Modesti V, Lorenzin M, Campana C, Punzi L. Erosive hand osteoarthritis and systemic sclerosis: a casual association? Joint Bone Spine 2012; 79:507-9. [PMID: 22840479 DOI: 10.1016/j.jbspin.2012.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 06/15/2012] [Indexed: 11/16/2022]
Abstract
To describe an unexpected association between a patient affected with erosive hand osteoarthritis (EHOA) and systemic sclerosis (SSc). We report a case of SSc presenting typical radiological findings of EHOA in a 60-year-old woman referred to our outpatient Rheumatology Unit. Physical examination revealed puffy hands with sclerodactyly and concomitant adduction of the thumb and subluxation of the first carpometacarpal (CMC) and metacarpophalangeal (MCP) joints bilaterally and nodose deformities of the distal interphalangeal (DIP). Hand X-rays showed joint space narrowing, osteophytosis and bone sclerosis of the proximal interphalangeal (PIP) joints. The DIP joints showed central bone erosion, collapse of the subchondral bone plate and typical "gull-wing" type deformity. EHOA is a particularly aggressive subset of osteoarthritis (OA). In light of its still unclear pathogenesis, peculiarities in the disease characteristics may be useful to better define the EHOA patient profile. One of these is an unexpected association with some autoimmune diseases. EHOA and SSc in the same patient is not uncommon, and it could speculate that there may be a genetic and autoimmune involvement.
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Affiliation(s)
- Roberta Ramonda
- Rheumatology Unit, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
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Ruffatti A, Del Ross T, Ciprian M, Bertero MT, Sciascia S, Salvatore S, Scarpato S, Montecucco C, Rossi S, Caramaschi P, Biasi D, Doria A, Rampudda M, Monica N, Fischetti F, Picillo U, Brucato A, Salvan E, Vittorio P, Meroni P, Tincani A. Risk factors for a first thrombotic event in antiphospholipid antibody carriers: a prospective multicentre follow-up study. Ann Rheum Dis 2011; 70:1083-6. [PMID: 21285115 DOI: 10.1136/ard.2010.142042] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess risk factors for a first thrombotic event in confirmed antiphospholipid (aPL) antibody carriers and to evaluate the efficacy of prophylactic treatments. METHODS Inclusion criteria were age 18-65 years, no history of thrombosis and two consecutive positive aPL results. Demographic, laboratory and clinical parameters were collected at enrolment, once a year during the follow-up and at the time of the thrombotic event, whenever that occurred. RESULTS 258 subjects were prospectively observed between October 2004 and October 2008. The mean ± SD follow-up was 35.0 ± 11.9 months (range 1-48). A first thrombotic event (9 venous, 4 arterial and 1 transient ischaemic attack) occurred in 14 subjects (5.4%, annual incidence rate 1.86%). Hypertension and lupus anticoagulant (LA) were significantly predictive of thrombosis (both at p<0.05) and thromboprophylaxis was significantly protective during high-risk periods (p<0.05) according to univariate analysis. Hypertension and LA were identified by multivariate logistic regression analysis as independent risk factors for thrombosis (HR 3.8, 95% CI 1.3 to 11.1, p<0.05, and HR 3.9, 95% CI 1.1 to 14, p<0.05, respectively). CONCLUSIONS Hypertension and LA are independent risk factors for thrombosis in aPL carriers. Thromboprophylaxis in these subjects should probably be limited to high-risk situations.
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy.
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