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Kim YH, Kim HJ, Park S, Hwang D, Kim HK, Huh S, Yun WS. Comparing clinical outcomes of Vitamin K antagonists versus Non-Vitamin K antagonists in anticoagulant therapy for mesenteric venous thrombosis. J Vasc Surg Venous Lymphat Disord 2024:101903. [PMID: 38754777 DOI: 10.1016/j.jvsv.2024.101903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 04/04/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Non-vitamin K antagonist oral anticoagulants have shown similar efficacy and lower bleeding rates than Vitamin K antagonists for venous thromboembolism. However, this has not been proven in mesenteric vein thrombosis. This study aimed to compare the clinical outcomes of vitamin K antagonists and non-vitamin K antagonist oral anticoagulants. METHODS Between Jan 2014 and July 2022, mesenteric vein thrombosis was diagnosed on computed tomography in 225 patients in a tertiary hospital. Among them, a total of 44 patients who underwent long-term anticoagulation therapy over 3 months were enrolled in this study. Patients were divided into two groups based on the anticoagulant used: vitamin K antagonists (Group 1, n = 21) and non-vitamin K antagonist oral anticoagulants (Group 2, n = 23). The efficacy outcomes were symptom recurrence and thrombus resolution on follow-up computed tomography, and the safety outcome was bleeding complications. RESULTS The median age of the patients was 56 years (46-68) and 52% were men. The most common risk factors were unprovoked intra-abdominal infections (30%). The median duration of anticoagulation therapy was 13 months (20 months in Group 1 vs. 6 months in Group 2; p = 0.076). Of the 44 patients, 17 (39%) received the standard treatment. The median follow-up period was longer in Group 1 than in Group 2 (57 vs. 28 months, p = 0.048). No recurrence of mesenteric vein thrombosis related symptoms were observed in either group. The median duration of follow-up computed tomography was 31 months (42 months in Group 1 vs. 18 months in Group 2; p = 0.064). Computed tomography revealed complete thrombus resolution, partial resolution, and no changes in 71%, 19%, and 10%, respectively (p = 0.075). Regarding bleeding complications, varix bleeding and melena developed in 2 patients in Group 2, and anticoagulation treatment thereafter ceased. CONCLUSIONS Despite the short follow-up duration in the non-vitamin K antagonist oral anticoagulants group, there was no clinically significant difference in the thrombus resolution rate or bleeding complications when compared with the vitamin K antagonists group. Although research on the long-term effects of non-vitamin K antagonist oral anticoagulants in patients is limited, non-vitamin K antagonist oral anticoagulants can be considered an alternative to conventional treatments.
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Affiliation(s)
- Young-Hye Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital
| | - Hyeon Ju Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital
| | - Suehyun Park
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Deokbi Hwang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital
| | - Hyung-Kee Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Seung Huh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital
| | - Woo-Sung Yun
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital,.
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2
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Sabina M, Barakat Z, Costa Guerra B, Lurie A, Khan Z. Vintage Victory: Warfarin Versus Apixaban in the Antiphospholipid Arena. Cureus 2024; 16:e57040. [PMID: 38681463 PMCID: PMC11046336 DOI: 10.7759/cureus.57040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
This case report explores the efficacy of warfarin compared to apixaban in managing antiphospholipid syndrome (APS), an autoimmune disorder characterized by recurrent thrombosis. We emphasize the constraints of direct oral anticoagulants (DOACs) such as apixaban in APS management. This case discusses a 41-year-old female patient with APS who did not respond to apixaban therapy. The report details her transition to warfarin, resulting in symptom resolution and no further complications, thus alluding to warfarin's effectiveness in APS management over apixaban. The case contributes to the ongoing debate on the suitability of modern DOACs in APS treatment.
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Affiliation(s)
- Michael Sabina
- Internal Medicine, Lakeland Regional Health Medical Center, Lakeland, USA
| | - Zein Barakat
- Internal Medicine, Lakeland Regional Health Medical Center, Lakeland, USA
| | | | - Andrew Lurie
- Research, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Zoya Khan
- Research, Lakeland Regional Health Medical Center, Lakeland, USA
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3
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Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a newly defined refractory adult-onset autoinflammatory syndrome caused by somatic mutations in the ubiquitin-like modifier-activating enzyme 1 (UBA1) gene in hematopoietic stem and progenitor cells, resulting in a shift in UBA1 isoform expression. Thus, patients develop a spectrum of systemic inflammatory manifestations and hematologic symptoms. To date, patients respond poorly to immune suppressive drugs, except high-dose glucocorticoids, and no treatment guidelines have been established. Given the high mortality rate, VEXAS syndrome needs to be taken seriously by physicians in all specialties. This article aims to describe the key features, pathogenesis, and clinical manifestations of VEXAS syndrome to better understand the targeted treatment and improve the prognosis of VEXAS syndrome.
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Affiliation(s)
- Yue Zhang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Xifeng Dong
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
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4
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Simaan N, Molad J, Honig A, Filioglo A, Peretz S, Shbat F, Mansor T, Abu-Shaheen W, Leker RR. Factors influencing real-life use of direct oral anticoagulants in patients with cerebral sinus and venous thrombosis. J Stroke Cerebrovasc Dis 2023; 32:107223. [PMID: 37437504 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) are advocated as equally effective to vitamin K antagonists (VKA) for the treatment of patients with cerebral sinus and venous thrombosis (CSVT). However, data concerning the real-life management practices in CSVT patients are is lacking. METHODS Prospective CSVT databases from four large academic medical centers were retrospectively studied. Demographics, clinical presentations, risk factors, radiological and outcome parameters were compared between CSVT patients treated with DOAC and VKA. RESULTS Out of 504 CSVT patients, 43 (8.5%) were treated with DOAC, and the remaining 461 (91.5%) were treated with VKA. All patients with antiphospholipid syndrome (APLA) were treated with VKA (61 vs. 0, p=0.013). Patients with a history or presence of malignancy were also more often treated with VKA (16% vs. 5%, p=0.046). Other risk factors for thrombosis did not differ between the groups. There were no differences in clot extent or location and no differences in the percentage of favorable outcomes or mortality were observed. CONCLUSION Our data suggests that only malignancy and antiphospholipid antibodies significantly influenced physician's decisions towards choosing VKA rather than DOAC. DOAC appear to be as effective and safe as VKA in patients with CSVT.
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Affiliation(s)
- Naaem Simaan
- Department of Neurology, Ziv Medical Center, Safed, Israel; The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Jeremy Molad
- Department of Neurology Tel Aviv Sourasky Medical Center, Israel
| | - Asaf Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem, 91120, Israel
| | - Andrei Filioglo
- Department of Neurology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem, 91120, Israel
| | - Shlomi Peretz
- Department of Neurology Rabin Medical Center, Petach Tikva, Israel
| | - Fadi Shbat
- Department of Neurology, Ziv Medical Center, Safed, Israel; The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Tarek Mansor
- Department of Neurology, Ziv Medical Center, Safed, Israel; The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Waleed Abu-Shaheen
- Department of Neurology, Ziv Medical Center, Safed, Israel; The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem, 91120, Israel.
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5
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Alferes D, Pereira S, Paes de Faria V, Ventura A, Almeida MC. Catastrophic Antiphospholipid Syndrome and Renal Failure: An Unexpected Recovery After Three Years on Dialysis. Cureus 2023; 15:e38851. [PMID: 37303325 PMCID: PMC10256277 DOI: 10.7759/cureus.38851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare and life-threatening disorder characterised by arterial or venous thrombotic events, involving three or more organs in a short period of time, in the presence of persistent antiphospholipid antibodies. Long-term anticoagulation with warfarin is the standard of care to prevent recurrent vascular events. Besides supportive care, optimal management of CAPS is unclear and consensus among experts is lacking. We describe a patient with primary antiphospholipid syndrome who experienced probable CAPS after receiving rivaroxaban, resulting in extensive cutaneous ulceration, acute coronary syndrome and dialysis-dependent renal failure. Anticoagulation, glucocorticoids and plasmapheresis were started. In the haemodialysis period, he maintained treatment with long-term vitamin K antagonist. The international normalized ratio target was optimized to 3.5-4. This strategy was associated with the healing of skin lesions, regression of cardiac lesions and recovery of renal function after three years on dialysis.
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Affiliation(s)
- Daniela Alferes
- Nephrology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PRT
- Nephrology, Nefrodouro Hemodialysis Clinic, Santa Maria da Feira, PRT
| | - Susana Pereira
- Nephrology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PRT
- Nephrology, Nefrodouro Hemodialysis Clinic, Santa Maria da Feira, PRT
| | - Vitória Paes de Faria
- Nephrology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PRT
- Nephrology, Nefrodouro Hemodialysis Clinic, Santa Maria da Feira, PRT
| | - Ana Ventura
- Nephrology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PRT
- Nephrology, Nefrodouro Hemodialysis Clinic, Santa Maria da Feira, PRT
| | - Maria Clara Almeida
- Nephrology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PRT
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6
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Lam K, Selim M. An Unusual Case of Catastrophic Antiphospholipid Syndrome in an Elderly Man. Cureus 2023; 15:e34810. [PMID: 36915843 PMCID: PMC10008068 DOI: 10.7759/cureus.34810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/11/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a condition in which the body produces antiphospholipid antibodies, resulting in arterial and venous thrombosis. Catastrophic antiphospholipid syndrome (CAPS) is a rare APS subtype characterized by acute thrombotic microangiography. Antiphospholipid antibodies cause thrombosis through activating and inhibiting properties. CAPS is caused by conditions or factors that trigger the production of antiphospholipid antibodies: genetics that increases the risk of antiphospholipid antibody-associated thrombosis, infection, surgery, medications, and malignancy. We present a unique case of CAPS in a 63-year-old male patient.
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Affiliation(s)
- Kayla Lam
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Mohammad Selim
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
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7
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Ivyanskiy I, Abdelbaki S, Qayyom MM, Horn R, Davey-Ranasinghe N. Newly Diagnosed SLE With APLS and Right Atrial Thrombus. J Investig Med High Impact Case Rep 2023; 11:23247096231192923. [PMID: 37584313 PMCID: PMC10434841 DOI: 10.1177/23247096231192923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 06/08/2023] [Accepted: 07/19/2023] [Indexed: 08/17/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder manifesting in myriad of forms and could affect almost any body system or organ. Antiphospholipid syndrome (APLS) is a relatively common scenario in SLE. Both arterial and venous thrombosis is a hallmark feature of APLS. Among others, intracardiac thrombus is a rare and potentially life-threatening presentation. It could occur in any heart chamber whereas the right atrium is the least common location. The treatment is based on anticoagulation preferably with warfarin along with treatment of SLE. We describe a young patient with newly diagnosed SLE with APLS complicated by right atrial thrombus formation. We are, therefore, adding to the scant literature on right atrial thrombi in SLE and increasing awareness of readers of this serious and potentially deadly condition if left unrecognized.
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Affiliation(s)
| | | | | | - Robin Horn
- Christiana Care Health System, Newark, Delaware, USA
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8
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Delavar A, Baxter SL. Cilioretinal artery occlusion in antiphospholipid syndrome and the decision to anticoagulate. BMJ Case Rep 2022; 15:e249509. [PMID: 36384882 PMCID: PMC9670929 DOI: 10.1136/bcr-2022-249509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A patient in her late 50s with antiphospholipid syndrome presented to general ophthalmology clinic for annual hydroxychloroquine retinopathy screening. She had taken 400 mg hydroxychloroquine daily for over a decade. She denied any visual changes and visual acuity was 20/20. Her examination and fundus photos were normal, but macular optical coherence tomography of the right eye demonstrated inner retinal atrophy and visual field tests revealed a corresponding paracentral scotoma, consistent with a prior cilioretinal artery occlusion. Prior testing from visits with other ophthalmologists revealed that this occlusion had occurred previously, but she had only been informed of not having hydroxychloroquine retinopathy. The possibility of vision loss prompted her to reconsider her prior decision to discontinue anticoagulation. This case demonstrates how anchoring bias may lead clinicians astray, and how the risk of blindness is a strong motivator for patients regarding anticoagulation.
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Affiliation(s)
- Arash Delavar
- Department of Ophthalmology, University of California, La Jolla, California, USA
- Department of Medicine, Division of Biomedical Informatics, University of California, La Jolla, California, USA
| | - Sally L Baxter
- Department of Ophthalmology, University of California, La Jolla, California, USA
- Department of Medicine, Division of Biomedical Informatics, University of California, La Jolla, California, USA
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9
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Sloan EE, McCurdy D. The Antiphospholipid Syndrome in the Pediatric Population. Adv Pediatr 2022; 69:107-121. [PMID: 35985703 DOI: 10.1016/j.yapd.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric antiphospholipid syndrome (APS) is characterized by autoantibodies directed against protein complexes on cellular membranes and leads to a prothrombotic, proinflammatory state. A child with APS may present with venous, arterial, or small vessel thrombosis. Other manifestations of APS include nonthrombotic manifestations, such as hematologic and neurologic symptoms. APS may be a primary condition or related to other autoimmune diseases. If APS-related thrombosis is unrecognized, the child may suffer recurrent thrombotic events after the withdrawal of anticoagulation. Thus, it is important to consider APS as a cause of thrombosis in children. Appropriate testing confirms the diagnosis and directs further care.
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Affiliation(s)
- Elizabeth E Sloan
- Department of Pediatrics, Division of Rheumatology, University of Texas Southwestern Medical Center, Scottish Rite for Children and Children's Medical Center Dallas, 2222 Welborn Street, Dallas, TX 75219, USA.
| | - Deborah McCurdy
- Department of Pediatrics, Division of Allergy/Immunology/Rheumatology, David Geffen School of Medicine, UCLA, Mattel Children's Hospital, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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10
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Cravero K, Maddy AJ, Motaparthi K. Digital ulcers as presenting symptom of secondary antiphospholipid syndrome. JAAD Case Rep 2022; 29:1-5. [PMID: 36186414 PMCID: PMC9519777 DOI: 10.1016/j.jdcr.2022.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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11
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Abdelnabi M, Benjanuwattra J, Okasha O, Almaghraby A, Saleh Y, Gerges F. Switching from warfarin to direct-acting oral anticoagulants: it is time to move forward! Egypt Heart J 2022; 74:18. [PMID: 35347478 PMCID: PMC8960500 DOI: 10.1186/s43044-022-00259-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/20/2022] [Indexed: 11/12/2022] Open
Abstract
Oral vitamin K antagonists (VKAs), warfarin, have been in routine clinical use for almost 70 years for various cardiovascular conditions. Direct-Acting Oral Anticoagulants (DOACs) have emerged as competitive alternatives for VKAs to prevent stroke in patients with non-valvular atrial fibrillation (AF) and have become the preferred choice in several clinical indications for anticoagulation. Recent guidelines have limited the use of DOACs to patients with non-valvular AF to reduce the risk of cardioembolic complications and to treat venous thromboembolism (VTE). Although emerging evidence is suggestive of its high efficacy, there was a lack of data to support DOACs safety profile in patients with mechanical valve prosthesis, intracardiac thrombi, or other conditions such as cardiac device implantation or catheter ablation. Therefore, several clinical trials have been conducted to assess the beneficial effects of using DOACs, instead of VKAs, for various non-guideline-approved indications. This review aimed to discuss the current guideline-approved indications for DOACs, advantages, and limitations of DOACs use in various clinical indications highlighting the potential emerging indications and remaining challenges for DOACs use. Several considerations are in favour of switching from warfarin to DOACs including superior efficacy, better adverse effect profile, fewer drug-drug interactions, and they do not require frequent international normalized ratio (INR) monitoring. Large randomized controlled trials are required to determine the safety and efficacy of their use in various clinical indications.
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Affiliation(s)
- Mahmoud Abdelnabi
- Internal Medicine Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA. .,Cardiology and Angiology Unit, Clinical and Experimental Internal Medicine Department, Alexandria University, Alexandria, Egypt.
| | - Juthipong Benjanuwattra
- Internal Medicine Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Osama Okasha
- Internal Medicine Department, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Abdallah Almaghraby
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yehia Saleh
- Cardiology Department, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Fady Gerges
- Department of Cardiovascular Science, Mediclinic Al Jowhara Hospital, Al Ain, UAE
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12
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Heiblig M, Patel BA, Groarke EM, Bourbon E, Sujobert P. Toward a pathophysiology inspired treatment of VEXAS syndrome. Semin Hematol 2021; 58:239-246. [PMID: 34802546 DOI: 10.1053/j.seminhematol.2021.09.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/03/2021] [Indexed: 02/06/2023]
Abstract
VEXAS syndrome has an unmet need for therapeutic interventions. Even if few data exist regarding the treatment of this newly described syndrome, different options can be proposed given the unique pathophysiological consequences of the clonal dominance of UBA1 mutated hematopoietic stem cells. To date, allogeneic transplantation is the only curative option, but many questions remain regarding the selection of eligible patients, the conditioning regimen or management of toxicities that may be unique to VEXAS patients. Alternatively, drugs used in myelodysplastic syndrome such as hypomethylating agents or lenalidomide are interesting candidates, which could theoretically have also an effect on the clone. Another strategy is to target the inflammatory cascade, by inhibiting proinflammatory cytokines (such as TNFα, IL1, IL6) or effector cells, for example with JAK inhibitors. Whatever the choice of treatment for VEXAS patients, supportive care is always needed to be considered to manage frequent complications such as cytopenia, thrombosis and infections. Finally, we discuss the challenges of the design of clinical trials for VEXAS patients, from inclusion criteria to clinical and biological endpoints of activity.
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Affiliation(s)
- Maël Heiblig
- Hospices Civils de Lyon. Hôpital Lyon Sud. Service d'hématologie clinique, Lyon, France
| | - Bhavisha A Patel
- Hematology Branch, National Heart, Lung, and Blood Institutes (NHLBI), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung, and Blood Institutes (NHLBI), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Estelle Bourbon
- Hospices Civils de Lyon. Hôpital Lyon Sud. Service d'hématologie biologique
| | - Pierre Sujobert
- Hospices Civils de Lyon. Hôpital Lyon Sud. Service d'hématologie biologique.
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13
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Lim W, Kaur A, Munoh Kenne F, Shulimovich M. A Difficult and Rare Case of Warfarin Refractory Antiphospholipid Syndrome Presenting With Catastrophic Antiphospholipid Syndrome Complicated by Gastrointestinal Bleeding. Cureus 2021; 13:e17106. [PMID: 34527491 PMCID: PMC8432969 DOI: 10.7759/cureus.17106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 11/05/2022] Open
Abstract
Antiphospholipid syndrome (APS) is managed with warfarin for secondary prophylaxis in patients who have had a thrombotic event in the past. Warfarin has been deemed superior to novel oral anticoagulants in preventing venous and arterial thrombosis in conjunction with aspirin. The catastrophic variant of APS (CAPS) is very rarely reported, especially in those who have been on a therapeutic dose of warfarin therapy. We present a rare case of CAPS in a patient with a history of APS who had been on a therapeutic dose of warfarin along with aspirin therapy. The patient is a 70-year-old male with APS diagnosed 30 years prior when he presented with a pulmonary embolism; aspirin was added to warfarin two years ago when he had a cerebrovascular accident (CVA). He presented to the hospital with acute onset right-sided weakness and aphasia, left lower extremity pain. He had ischemic CVA, acute deep vein thrombosis (DVT), acute renal failure with a creatinine of 2.8, anemia with hemoglobin of 3.8, gastrointestinal bleed (GIB) on EGD, with INR of 3.48 cardiolipin IgM of >140g/L. He was transfused packed red blood cells, fresh frozen plasma, and provided Vit K. Subsequently, he had a cardiac arrest and was intubated and placed on a mechanical ventilator. Given simultaneous multiorgan involvement, acute arterial and venous thrombosis, the patient was diagnosed with CAPS. The patient was started on high-dose dexamethasone, intravenous immunoglobulin (IVIG), and underwent plasma exchange with significant improvement in symptoms, laboratory parameters; and was extubated with near normalization of his speech and motor deficits. He was discharged on enoxaparin and prednisone with sustained clinical improvement two months following discharge. This patient was on the recommended treatment for APS. However, he had presented with a CAPS. This is the first reported case of warfarin refractory CAPS. This case highlights that there might be a subgroup of the population in whom warfarin is not an effective form of treatment modality for an unknown cause, and in fact, it could potently expose a patient to the adverse events related to warfarin therapy as it did in our patient who had significant GIB. This case also highlights the uncommon scenario of spontaneous CAPS with no inciting event as previously reported in the literature, such as infection, recent surgeries, or trauma.
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Affiliation(s)
- William Lim
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Amandeep Kaur
- Hematology and Medical Oncology, Richmond University Medical Center, Staten Island, USA
| | - Foma Munoh Kenne
- Hematology and Medical Oncology, Richmond University Medical Center, Staten Island, USA
| | - Maxim Shulimovich
- Hematology and Medical Oncology, Brooklyn Cancer Care, Brooklyn, USA
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14
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Sayar Z, Nallamilli S, Efthymiou M, Lambert J, Cohen H. Coexistent antiphospholipid syndrome and myeloproliferative neoplasm. Lupus 2021; 30:1502-1508. [PMID: 34192956 DOI: 10.1177/09612033211021154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiphospholipid syndrome (APS) and myeloproliferative neoplasms (MPN) are associated with an increased risk of thrombosis. The optimal management of patients with coexistent APS and MPN has not been defined. A single centre and systematic literature review of patients with coexistent APS and MPN was performed. Cases were divided into two groups based on whether they met international consensus criteria for APS. Of the 12 studies identified, eight were excluded (leaving five of a total 54 patients), as although antiphospholipid antibodies (aPL) were documented, the diagnosis of APS was not conclusively demonstrated. Another ten patients with definite APS were identified at our centre. Fifteen patients (ten females, five males) were therefore included in this analysis (eleven definite APS and four highly likely), median age 44 (range: 13-71) years. Nine had polycythaemia vera and six, essential thrombocythaemia. Thirteen of the 15 patients (86.7%) had thrombotic APS (seven with initial venous events and six arterial) and two (13.3%) had obstetric APS. Nine patients were single-positive, and six double-positive for aPL. None were triple aPL-positive. Four patients at our centre had recurrent thrombotic/obstetric events, including while on anticoagulation/antiplatelet treatment.
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Affiliation(s)
- Zara Sayar
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Susanna Nallamilli
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK.,Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK.,Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jonathan Lambert
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK.,Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Alhmoud EN, Elewa H, Abdul Gelil MS, Abd El Samad OB, Elzouki AY. Evaluation of the Validity of SAMe-TT 2R 2 Score in a Cohort of Venous Thromboembolism Patients Treated With Warfarin. Clin Appl Thromb Hemost 2021; 26:1076029620945039. [PMID: 32875827 PMCID: PMC7476333 DOI: 10.1177/1076029620945039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Low SAMe-TT2R2 score of <2 was validated as a predictor of optimum anticoagulation control, reflected by mean time in therapeutic range (TTR) above 65% to 70%, among warfarin-treated atrial fibrillation patients. This study aimed to validate the ability of SAMe-TT2R2 score and its individual components in predicting anticoagulation control (mean TTR and clinical events) among a cohort of venous thromboembolism (VTE) patients in Qatar. A total of 295 patients were retrospectively evaluated. There was a trend toward statistical significance in mean TTR between low (<2) and high (≥ 2) SAMe-TT2R2 score groups (P = .05), a difference that was not sustained when a cutoff of 3 was used (ie, a score of 3 or more). Patients with poor INR control (TTR <70%) were numerically less likely to have SAMe-TT2R2 score of <2 compared with those with good INR control, though the difference was not statistically significant (16.7% vs 83.3%, respectively, P = .4). No thromboembolic events were reported, and no association was found between the score and risk of bleeding. Non-Caucasian origin was the only significant predictor of good anticoagulation in the studied cohort. In conclusion, SAMe-TT2R2 score could not predict quality of anticoagulation control in a cohort of VTE patients treated with warfarin in Qatar. Contribution of other clinical factors and whether a different scoring may yield better prediction of anticoagulation control remains to be tested.
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Affiliation(s)
| | - Hazem Elewa
- 235883College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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16
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Uludag G, Onghanseng N, Tran ANT, Hassan M, Halim MS, Sepah YJ, Do DV, Nguyen QD. Current concepts in the diagnosis and management of antiphospholipid syndrome and ocular manifestations. J Ophthalmic Inflamm Infect 2021; 11:11. [PMID: 33834305 PMCID: PMC8032459 DOI: 10.1186/s12348-021-00240-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 03/02/2021] [Indexed: 12/18/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder associated with obstetrical complications, thrombotic complications involving both arteries and veins, and non-thrombotic manifestations affecting multiple other systems presenting in various clinical forms. Diagnosis requires the presence of antiphospholipid antibodies. The exact pathogenesis of APS is not fully known. However, it has recently been shown that activation of different types of cells by antiphospholipid antibodies plays an important role in thrombosis formation. Ocular involvement is one of the important clinical manifestations of APS and can vary in presentations. Therefore, as an ophthalmologist, it is crucial to be familiar with the ocular findings of APS to prevent further complications that can develop. Furthermore, the ongoing identification of new and specific factors contributing to the pathogenesis of APS may provide new therapeutic options in the management of the disease in the future.
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Affiliation(s)
- Gunay Uludag
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Neil Onghanseng
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Anh N T Tran
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Muhammad Hassan
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Muhammad Sohail Halim
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.,Ocular Imaging Research and Reading Center, Sunnyvale, CA, USA
| | - Yasir J Sepah
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.,Ocular Imaging Research and Reading Center, Sunnyvale, CA, USA
| | - Diana V Do
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Quan Dong Nguyen
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.
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17
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Respiratory Manifestations in Systemic Lupus Erythematosus. Pharmaceuticals (Basel) 2021; 14:ph14030276. [PMID: 33803847 PMCID: PMC8003168 DOI: 10.3390/ph14030276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by a wide spectrum of clinical manifestations. The respiratory system can be involved in up to 50-70% of patients and be the presenting manifestation of the disease in 4-5% of cases. Every part of the respiratory part can be involved, and the severity can vary from mild self-limiting to life threatening forms. Respiratory involvement can be primary (caused by SLE itself) or secondary (e.g., infections or drug toxicity), acute or chronic. The course, treatment and prognosis vary greatly depending on the specific pattern of the disease. This review article aims at providing an overview of respiratory manifestations in SLE along with an update about therapeutic approaches including novel biologic therapies.
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18
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McRae HL, Militello L, Refaai MA. Updates in Anticoagulation Therapy Monitoring. Biomedicines 2021; 9:262. [PMID: 33800804 PMCID: PMC8001784 DOI: 10.3390/biomedicines9030262] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/29/2022] Open
Abstract
In the past six decades, heparin and warfarin were the primary anticoagulants prescribed for treatment and prophylaxis of venous thromboembolism worldwide. This has been accompanied by extensive clinical knowledge regarding dosing, monitoring, and reversal of these anticoagulants, and the resources required to do so have largely been readily available at small and large centers alike. However, with the advent of newer oral and parenteral anticoagulants such as low molecular weight heparins, factor Xa inhibitors, and direct thrombin inhibitors in recent years, new corresponding practice guidelines have also emerged. A notable shift in the need for monitoring and reversal agents has evolved as well. While this has perhaps streamlined the process for physicians and is often desirable for patients, it has also left a knowledge and resource gap in clinical scenarios for which urgent reversal and monitoring is necessary. An overview of the currently available anticoagulants with a focus on the guidelines and available tests for anticoagulant monitoring will be discussed in this article.
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Affiliation(s)
| | | | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY 14642, USA; (H.L.M.); (L.M.)
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19
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Dafer RM. Neurologic complications of nonbacterial thrombotic endocarditis. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:135-141. [PMID: 33632431 DOI: 10.1016/b978-0-12-819814-8.00013-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endocarditis is an inflammatory or infective condition affecting the cardiac valves or endocardium, often associated with serious neurological sequelae. Nonbacterial thrombotic endocarditis (NBTE)-referred to as degenerative, Libman-Sachs, marantic, verrucous, or terminal endocarditis-is a serious but rare cause of valvular heart disease characterized by deposition of sterile vegetations of fibrin and platelet aggregates on the cardiac valves, eventually resulting in life-threatening embolization of these thrombi to the brain, limbs, or visceral organs. NBTE may complicate a heterogeneous group of chronic conditions, predominantly connective tissue and autoimmune disorders, malignancies, and diseases associated with hypercoagulability states. NBTE usually affects the native rather than prosthetic valves, and unlike infective endocarditis (IE), sparing the involved valve function without its destruction. Compared to those seen in IE, vegetations in NBTE are small and friable, thus may easily be dislodged leading to systemic thromboembolism with devastating morbidities and mortality. There are no diagnostic criteria for NBTE, and antemortem diagnosis is challenging. The condition should be suspected in patients with thromboembolic events and vegetations on the cardiac valves on echocardiographic or cardiac imaging studies, in the absence of underlying infection, especially in disorders predisposing to coagulopathy. Early recognition and prompt treatment of the primary underlying disorder is essential. Anticoagulation with heparin or heparinoid products is recommended to prevent recurrent embolism. Surgical intervention is not indicated except in selected patients with life-threatening recurrent embolism.
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Affiliation(s)
- Rima M Dafer
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States.
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20
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Ischemic Stroke in a Young Patient with Nephrotic Syndrome and Antiphospholipid Syndrome. Case Rep Nephrol 2020; 2020:8828864. [PMID: 33294240 PMCID: PMC7718048 DOI: 10.1155/2020/8828864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 11/18/2022] Open
Abstract
We report a case of a 21-year-old man with underlying nephrotic syndrome (NS) secondary to minimal change disease, who developed an ischemic stroke with left hemiparesis. He received intravenous thrombolysis followed by a mechanical thrombectomy. After mechanical thrombectomy, he developed acute kidney injury which subsequently required haemodialysis. Further workup revealed that he had concomitant antiphospholipid syndrome (APS) and NS. He was started on vitamin K antagonist anticoagulant. This case report illustrates the importance of workup in identifying causes of ischemic stroke in a young patient.
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21
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Dreucean D, Nguyen SN, Donahue KR, Salazar E, Ruegger MC. Evaluation of characteristics and dosing regimens in patients with new or recurrent thrombosis on apixaban and rivaroxaban. J Thromb Thrombolysis 2020; 52:161-169. [PMID: 33099722 DOI: 10.1007/s11239-020-02308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
Direct factor Xa inhibitors, such as apixaban and rivaroxaban, are widely used for treatment and prevention of venous thromboembolism; however, recent cases of therapeutic failure have been reported. Potential risk factors associated with therapeutic failure such as dose deviations outside of package labeling recommendations, and the use of direct factor Xa-specific inhibitor levels to guide clinical decision making continue to be areas of further investigation. Our study aimed to describe characteristics and dosing regimens in patients on apixaban or rivaroxaban who experienced a new or recurrent thrombosis. We performed a retrospective chart review on 190 patients on either apixaban or rivaroxaban presenting to our institution with new or breakthrough thromboembolism. Evaluation of prescribed anticoagulation regimens compared to package labeling recommendations, direct factor Xa inhibitor-specific anti-Xa levels, anticoagulation interruptions, use of parenteral bridge anticoagulation, final anticoagulation regimen disposition, and thrombosis-associated mortality were recorded. In patients presenting with breakthrough thromboembolism, 78% were on a regimen that matched package labeling recommendations. Anti-Xa levels were documented in 66 patients, the majority of which fell within institutional expected ranges at time of thrombosis. Therapy interruptions immediately prior to thrombosis were observed in 22% of patients and 21% of those patients received parenteral anticoagulation during interruption. Upon discharge, 46% of patients continued the same anticoagulation regimen with no changes. The mortality rate was 6%. In patients who present with new thromboembolism on apixaban or rivaroxaban, a thorough review of risks and benefits should be conducted to mitigate future risk of recurrent thrombosis.
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Affiliation(s)
- Diane Dreucean
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA.
| | - Steffany N Nguyen
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
| | - Kevin R Donahue
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
| | - Eric Salazar
- Department of Pathology and Genomic Medicine - Houston Methodist Hospital, 6565 Fannin St, Houston, TX, 77030, USA
| | - Melanie C Ruegger
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
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22
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Bala MM, Celinska-Lowenhoff M, Szot W, Padjas A, Kaczmarczyk M, Swierz MJ, Undas A. Antiplatelet and anticoagulant agents for secondary prevention of stroke and other thromboembolic events in people with antiphospholipid syndrome. Cochrane Database Syst Rev 2020; 10:CD012169. [PMID: 33045766 PMCID: PMC8094585 DOI: 10.1002/14651858.cd012169.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial or venous thrombosis (or both), and/or pregnancy morbidity in association with the presence of antiphospholipid antibodies. The prevalence of APS is estimated at 40 to 50 cases per 100,000 people. The most common sites of thrombosis are cerebral arteries and deep veins of the lower limbs. People with a definite APS diagnosis have an increased lifetime risk of recurrent thrombotic events. OBJECTIVES To assess the effects of antiplatelet (AP) or anticoagulant agents, or both, for the secondary prevention of recurrent thrombosis, particularly ischemic stroke, in people with APS. SEARCH METHODS We last searched the MEDLINE, Embase, CENTRAL, Cochrane Stroke Group Trials Register, and ongoing trials registers on 22 November 2019. We checked reference lists of included studies, systematic reviews, and practice guidelines. We also contacted experts in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated any anticoagulant or AP agent, or both, in the secondary prevention of thrombosis in people with APS, according to the criteria valid when the study took place. We did not include studies specifically addressing women with obstetrical APS. DATA COLLECTION AND ANALYSIS Pairs of review authors independently worked on each step of the review, following Cochrane methods. We summarized the evidence using the GRADE approach. MAIN RESULTS We identified eight studies including 811 participants that compared different AP or anticoagulant agents. NOAC (non-VKA oral anticoagulant: rivaroxaban 15 or 20 mg/d) versus standard-dose VKA (vitamin K antagonist: warfarin at moderate International Normalized Ratio [INR] - 2.5) or adjusted [INR 2.0-3.0] dose): In three studies there were no differences in any thromboembolic event (including death) and major bleeding (moderate-certainty evidence), but an increased risk of stroke (risk ratio [RR] 14.13, 95% confidence interval [CI] 1.87 to 106.8; moderate-certainty evidence). One of the studies reported a small benefit of rivaroxaban in terms of quality of life at 180 days measured as health state on Visual Analogue Scale (mean difference [MD] 7 mm, 95% CI 2.01 to 11.99; low-certainty evidence), but not measured as health utility on a scale from 0 to 1 (MD 0.04, 95% CI -0.02 to 0.10; low-certainty evidence). High-dose VKA (warfarin with a target INR of 3.1 to 4.0 [mean 3.3] or 3.5 [mean 3.2]) versus standard-dose VKA (warfarin with a target INR of 2.0 to 3.0 [mean 2.3] or 2.5 [mean 2.5]): In two studies there were no differences in the rates of thrombotic events and major bleeding (RR 2.22, 95% CI 0.79 to 6.23, low-certainty evidence), but an increased risk of minor bleeding in one study during a mean of 3.4 years (standard deviation [SD] 1.2) of follow-up (RR 2.55, 95% CI 1.07 to 6.07). In both trials there was evidence of a higher risk of any bleeding (hazard ratio [HR] 2.03 95% CI 1.12 to 3.68; low-certainty evidence) in the high-dose VKA group, and for this outcome (any bleeding) the incidence is not different, only the time to event is showing an effect. Standard-dose VKA plus a single AP agent (warfarin at a target INR of 2.0 to 3.0 plus aspirin 100 mg/d) versus standard-dose VKA (warfarin at a target INR of 2.0 to 3.0): One high-risk-of-bias study showed an increased risk of any thromboembolic event with combined treatment (RR 2.14, 95% CI 1.04 to 4.43; low-certainty evidence) and reported on major bleeding with five cases in the combined treatment group and one case in the standard-dose VKA treatment group, resulting in RR 7.42 (95% CI 0.91 to 60.7; low-certainty evidence) and no differences for secondary outcomes (very low- to low-certainty evidence). Single/dual AP agent and standard-dose VKA (pooled results): Two high-risk-of-bias studies compared a combination of AP and VKA (aspirin 100 mg/d plus warfarin or unspecified VKA at a target INR of 2.0 to 3.0 or 2.0 to 2.5) with a single AP agent (aspirin 100 mg/d), but did not provide any conclusive evidence regarding the effects of those drugs in people with APS (very low-certainty evidence). One of the above-mentioned studies was a three-armed study that compared a combination of AP and VKA (aspirin 100 mg/d plus warfarin at a target INR of 2.0 to 2.5) with dual AP therapy (aspirin 100 mg/d plus cilostazol 200 mg/d) and dual AP therapy (aspirin 100 mg/d plus cilostazol 200 mg/d) versus a single AP treatment (aspirin 100 mg/d). This study reported on stroke (very low-certainty evidence) but did not report on any thromboembolic events, major bleeding, or any secondary outcomes. We identified two ongoing studies and three studies are awaiting classification. AUTHORS' CONCLUSIONS The evidence identified indicates that NOACs compared with standard-dose VKAs may increase the risk of stroke and do not appear to alter the risk of other outcomes (moderate-certainty evidence). Using high-dose VKA versus standard-dose VKA did not alter the risk of any thromboembolic event or major bleeding but may increase the risk of any form of bleeding (low-certainty evidence). Standard-dose VKA combined with an AP agent compared with standard-dose VKA alone may increase the risk of any thromboembolic event and does not appear to alter the risk of major bleeding or other outcomes (low-certainty evidence). The evidence is very uncertain about the benefit or harm of using standard-dose VKA plus AP agents versus single or dual AP therapy, or dual versus single AP therapy, for the secondary prevention of recurrent thrombosis in people with APS (very low-certainty evidence).
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Affiliation(s)
- Malgorzata M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
- Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Celinska-Lowenhoff
- 2nd Department of Internal Medicine, Department of Allergy and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Szot
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Padjas
- 2nd Department of Internal Medicine, Department of Allergy and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Kaczmarczyk
- Systematic Reviews Unit - Polish Cochrane Branch, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz J Swierz
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
- Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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23
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Cerdà P, Becattini C, Iriarte A, Hernández JC, Corbella X, Riera-Mestre A. Direct oral anticoagulants versus vitamin K antagonists in antiphospholipid syndrome: A meta-analysis. Eur J Intern Med 2020; 79:43-50. [PMID: 32482595 DOI: 10.1016/j.ejim.2020.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Anticoagulant treatment is recommended in patients with thrombosis and antiphospholipid syndrome (APS). Conflicting results have been reported on the role of direct oral anticoagulants (DOACs) in these patients. We performed a meta-analysis of randomized controlled trials (RCTs) focused on this issue. METHODS We searched MEDLINE and EMBASE for RCTs comparing DOACs and vitamin K antagonists (VKAs) for secondary thromboprophylaxis in patients with thrombotic APS. The primary objective was to assess the efficacy of DOACs compared to VKAs to prevent recurrence of thromboembolic events. Risk difference (RD) was reported as weighted RD according to Mantel-Haenszel random-effect method. RESULTS Three RCTs (426 patients) were included, all comparing rivaroxaban with VKAs. The proportion of recurrences (either arterial or venous) was higher among rivaroxaban patients when compared with those receiving VKAs (9.5% vs 2.8%; RD 6%, 95% CI, -0.05 - 0.18, p=0.29), although non-statistically significant. In patients with an arterial index event, thromboembolic recurrences were more frequent in those treated with rivaroxaban compared to those treated with VKAs (25% vs 6.2%; RD 19%, 95% CI, 0.04 - 0.33; p =0.01; I2 49%). In triple aPL positive patients, rivaroxaban showed higher rates of thromboembolic recurrences compared with VKAs (12% vs 3%; RD 9%, 95% CI, 0.02 - 0.15; p= 0.01; I2 13%). Non-statistically significant differences were observed in major bleeding events or mortality. CONCLUSIONS The use of rivaroxaban in APS patients is associated with an increased rate of thromboembolic recurrences compared to VKAs, at least in those with arterial index event or triple aPL positivity.
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Affiliation(s)
- Pau Cerdà
- Internal Medicine Department, Hospital Universitari Bellvitge - IDIBELL, Barcelona, Spain
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Adriana Iriarte
- Internal Medicine Department, Hospital Universitari Bellvitge - IDIBELL, Barcelona, Spain
| | - Josefina Cortés Hernández
- Internal Medicine Department. Rheumatology Research Group. Vall d´Hebrón University Hospital Research Institute, Barcelona, Spain
| | - Xavier Corbella
- Internal Medicine Department, Hospital Universitari Bellvitge - IDIBELL, Barcelona, Spain; Faculty of Medicine and Health Sciences. Universitat Internacional de Catalunya, Barcelona, Spain
| | - Antoni Riera-Mestre
- Internal Medicine Department, Hospital Universitari Bellvitge - IDIBELL, Barcelona, Spain; Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
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Sasi S, Ahmed A, Yousuf W, Vattoth S. Artery of Percheron Infarct: A Rare Presentation of Acute Ischemic Stroke in a High-Risk Antiphospholipid Syndrome Patient. CASE REPORTS IN ACUTE MEDICINE 2020. [DOI: 10.1159/000509569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Artery of Percheron (AOP) is an abnormal variant of the arterial supply of the thalamus. AOP occlusion can lead to bilateral thalamic and rostral midbrain infarct presenting as memory loss, fluctuating levels of consciousness, and altered mental status. A 43-year-old woman with a history of antiphospholipid syndrome (APS), managed on dabigatran, presented with acute confusion and drowsiness. She had slurred and slowed speech, disorientation in time and place, left-sided facial droop, decreased power of the left side (4/5), and was unable to walk due to generalized weakness. Labs showed a prolonged prothrombin time and activated partial thromboplastin time, positive lupus anticoagulant, anti-cardiolipin, beta-2 glycoprotein, anti-nuclear and anti-dsDNA antibodies. Contrast-enhanced CT perfusion showed ischemic changes in the bilateral thalami, suggesting infarct along the AOP territory. AOP infarcts are scarce and the presenting complaints are unusual of cerebrovascular accidents. It requires a high index of suspicion to detect. There are no other reports in the literature of patients with APS presenting with an AOP infarct. Considering the lack of evidence, we recommend against the use of newer oral anticoagulants (NOACs) for secondary prevention of vascular events in patients with triple-positive APS.
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25
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New Insights into the Use of Direct Oral Anticoagulants in Non-high Risk Thrombotic APS Patients: Literature Review and Subgroup Analysis from a Meta-analysis. Curr Rheumatol Rep 2020; 22:25. [DOI: 10.1007/s11926-020-00901-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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26
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Stammler R, Legendre P, Cacoub P, Blanche P, Piette JC, Costedoat -Chalumeau N. Catastrophic antiphospholipid syndrome following the introduction of rivaroxaban. Lupus 2020; 29:787-790. [DOI: 10.1177/0961203320914363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Summary Catastrophic antiphospholipid syndrome is the most severe complication of antiphospholipid syndrome. Vitamin K antagonists are the reference treatment for preventing relapsing thrombotic complications in patients with antiphospholipid syndrome. Direct oral anticoagulants are nonetheless sometimes used in this setting. We report two cases of women who were triple-positive for antiphospholipid antibodies and developed catastrophic antiphospholipid syndrome in the week after the introduction of rivaroxaban. The first patient, who had had a previous thrombotic event, had multiorgan failure 3 days after vitamin K antagonists was replaced by rivaroxaban, and the second developed a similar clinical presentation 7 days after introduction of the same treatment. Both catastrophic antiphospholipid syndrome episodes were successfully treated with heparin followed by vitamin K antagonists, corticosteroids, and plasmapheresis. These two cases highlight for the inefficacy of rivaroxaban preventing severe thrombotic events such as catastrophic antiphospholipid syndrome and thus provide further support for recommendations that vitamin K antagonists must remain the reference anticoagulant in patients with triple-positive antiphospholipid antibodies.
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Affiliation(s)
- Romain Stammler
- Internal Medicine Department, Cochin Hospital, Paris, France
| | - Paul Legendre
- Internal Medicine Department, Cochin Hospital, Paris, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, La Pitié-Salpêtrière Hospital, Paris, France
| | | | - Jean -Charles Piette
- Department of Internal Medicine and Clinical Immunology, La Pitié-Salpêtrière Hospital, Paris, France
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27
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Successful treatment with rivaroxaban for an acute pulmonary thromboembolism in a patient with primary antiphospholipid antibody syndrome. J Cardiol Cases 2020; 21:79-81. [DOI: 10.1016/j.jccase.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/09/2019] [Accepted: 09/30/2019] [Indexed: 11/17/2022] Open
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Fazili M, Stevens SM, Woller SC. Direct oral anticoagulants in antiphospholipid syndrome with venous thromboembolism: Impact of the European Medicines Agency guidance. Res Pract Thromb Haemost 2020; 4:9-12. [PMID: 31989078 PMCID: PMC6971326 DOI: 10.1002/rth2.12287] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 10/25/2019] [Accepted: 10/29/2019] [Indexed: 12/25/2022] Open
Affiliation(s)
- Masarret Fazili
- Department of MedicineIntermountain Medical CenterMurrayUtah
| | - Scott M. Stevens
- Department of MedicineIntermountain Medical CenterMurrayUtah
- Division of General Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtah
| | - Scott C. Woller
- Department of MedicineIntermountain Medical CenterMurrayUtah
- Division of General Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtah
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Derebail VK, Rheault MN, Kerlin BA. Role of direct oral anticoagulants in patients with kidney disease. Kidney Int 2019; 97:664-675. [PMID: 32107019 DOI: 10.1016/j.kint.2019.11.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderate-to-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.
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Affiliation(s)
- Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's, Columbus, Ohio, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Ordi-Ros J, Sáez-Comet L, Pérez-Conesa M, Vidal X, Riera-Mestre A, Castro-Salomó A, Cuquet-Pedragosa J, Ortiz-Santamaria V, Mauri-Plana M, Solé C, Cortés-Hernández J. Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome: A Randomized Noninferiority Trial. Ann Intern Med 2019; 171:685-694. [PMID: 31610549 DOI: 10.7326/m19-0291] [Citation(s) in RCA: 175] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The potential role of new oral anticoagulants in antiphospholipid antibody syndrome (APS) remains uncertain. OBJECTIVE To determine whether rivaroxaban is noninferior to dose-adjusted vitamin K antagonists (VKAs) for thrombotic APS. DESIGN 3-year, open-label, randomized noninferiority trial. (EU Clinical Trials Register: EUDRA [European Union Drug Regulatory Authorities] code 2010-019764-36). SETTING 6 university hospitals in Spain. PARTICIPANTS 190 adults (aged 18 to 75 years) with thrombotic APS. INTERVENTION Rivaroxaban (20 mg/d or 15 mg/d, according to renal function) versus dose-adjusted VKAs (target international normalized ratio, 2.0 to 3.0, or 3.1 to 4.0 in patients with a history of recurrent thrombosis). MEASUREMENTS The primary efficacy outcome was the proportion of patients with new thrombotic events; the primary safety outcome was major bleeding. The prespecified noninferiority margin for risk ratio (RR) was 1.40. Secondary outcomes included time to thrombosis, type of thrombosis, changes in biomarker levels, cardiovascular death, and nonmajor bleeding. RESULTS After 3 years of follow-up, recurrent thrombosis occurred in 11 patients (11.6%) in the rivaroxaban group and 6 (6.3%) in the VKA group (RR in the rivaroxaban group, 1.83 [95% CI, 0.71 to 4.76]). Stroke occurred more commonly in patients receiving rivaroxaban (9 events) than in those receiving VKAs (0 events) (corrected RR, 19.00 [CI, 1.12 to 321.9]). Major bleeding occurred in 6 patients (6.3%) in the rivaroxaban group and 7 (7.4%) in the VKA group (RR, 0.86 [CI, 0.30 to 2.46]). Post hoc analysis suggested an increased risk for recurrent thrombosis in rivaroxaban-treated patients with previous arterial thrombosis, livedo racemosa, or APS-related cardiac valvular disease. LIMITATION Anticoagulation intensity was not measured in the rivaroxaban group. CONCLUSION Rivaroxaban did not show noninferiority to dose-adjusted VKAs for thrombotic APS and, in fact, showed a non-statistically significant near doubling of the risk for recurrent thrombosis. PRIMARY FUNDING SOURCE Bayer Hispania.
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Affiliation(s)
- Josep Ordi-Ros
- Vall d'Hebrón Research Institute, Barcelona, Spain (J.O., X.V., C.S., J.C.)
| | | | | | - Xavier Vidal
- Vall d'Hebrón Research Institute, Barcelona, Spain (J.O., X.V., C.S., J.C.)
| | | | | | | | | | | | - Cristina Solé
- Vall d'Hebrón Research Institute, Barcelona, Spain (J.O., X.V., C.S., J.C.)
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Lavoipierre V, Talbot M, Soubrier C, De Sainte Marie B, Seux V, Solas C, Morange P, Bernit E, Ebbo M, Faucher B, Harlé JR, Schleinitz N. [Bilateral adrenal hemorrhage under apixaban in primary antiphospholipid syndrome]. Rev Med Interne 2019; 41:489-492. [PMID: 31672255 DOI: 10.1016/j.revmed.2019.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 08/27/2019] [Accepted: 09/26/2019] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Adrenal hemorrhage is a classical but rare complication of antiphospholipid syndrome, revealing diagnosis in one third of the cases. Anti-vitamin K therapy is the standard treatment but direct oral anticoagulants are discussed as an alternative. In the latest recommendations, it is advised not to use direct oral anticoagulants in the setting of antiphospholipid syndrome. CASE REPORT We present a case of bilateral adrenal hemorrhage revealing primary antiphospholipid syndrome with triple positive antibody profile, in a 47-year-old man treated by apixaban for previous venous thromboembolism. CONCLUSION To our knowledge, it is the first case of adrenal hemorrhage occurring during apixaban treatment in a patient with antiphospholipid syndrome. This case illustrates the inefficacy of direct oral anticoagulants to prevent thrombotic events in antiphospholipid syndrome, in accordance with the latest recommendations.
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Affiliation(s)
- V Lavoipierre
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
| | - M Talbot
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
| | - C Soubrier
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
| | - B De Sainte Marie
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
| | - V Seux
- Centre hospitalier de La Ciotat, service de médecine, Dr Valérie Seux, 13708 La Ciotat, France.
| | - C Solas
- Laboratoire de pharmacocinétique et de toxicocinétique, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Dr Bruno Lacarelle, 13005 Marseille, France.
| | - P Morange
- Laboratoire d'hématologie biologique, CHU de Timone et CHU du Nord, Assistance Publique Hôpitaux de Marseille, Pr Pierre Morange, 13005 Marseille, France.
| | - E Bernit
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
| | - M Ebbo
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
| | - B Faucher
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
| | - J R Harlé
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
| | - N Schleinitz
- Service de médecine interne, CHU de Timone, Assistance Publique Hôpitaux de Marseille, Pr Jean-Robert Harlé, 13005 Marseille, France.
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Riga JP, Leone A, Lambot F, Cappeliez O, Friart A. A microvascular myocardial infarction in a 16-year-old girl with antiphospholipid syndrome: a case report. Acta Clin Belg 2019; 74:351-354. [PMID: 30160190 DOI: 10.1080/17843286.2018.1516182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective and importance: The antiphospholipid syndrome can manifest itself by silent (or not) myocardial infarction. Clinical presentation: We report the case of a 16-year-old girl who presented a myocardial infarction for whom a coronary-computer tomography did not reveal any coronary abnormalities or obstruction. She had a livedo reticularis on her physical exam. Intervention: The echocardiography showed a normal left ventricular function and a mild eccentric mitral regurgitation. A myocardial magnetic resonance imaging demonstrated transmural necrosis with microvascular obstruction at the inferobasal segment of the left ventricle, suggestive of a microvascular myocardial infarction. The blood test showed elevation of the three antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, and anti-β2-glycoprotein). The lupus anticoagulant remained positive 12 weeks later, fulfilling the laboratory criteria for antiphospolipid carrier. The associated presence of this microvascular coronary obstruction was strongly suggestive of antiphospholipd syndrome, according to the revised Sapporo criteria. To our knowledge, this is the first reported case of antiphospholipid syndrome manifesting as an acute microvascular myocardial infarction, confirmed by myocardial magnetic resonance imaging. Conclusion: The antiphospholipid syndrome can manifest itself early by a microvascular myocardial infarction. The clinician has to be alerted by a livedo reticularis in these patients, which will be frequently associated with manifestations of antiphospholipid syndrome such as arterial thrombosis and valvulopathies.
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Affiliation(s)
- Jean-Philippe Riga
- Cardiology, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Attilio Leone
- Cardiology, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Frédéric Lambot
- Internal Medicine, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Olivier Cappeliez
- Medical Imaging, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Alain Friart
- Cardiology, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
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Management of Antiphospholipid Syndrome in Patients with Systemic Lupus Erythematosus. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00126-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sanchez-Redondo J, Espinosa G, Varillas Delgado D, Cervera R. Recurrent Thrombosis With Direct Oral Anticoagulants in Antiphospholipid Syndrome: A Systematic Literature Review and Meta-analysis. Clin Ther 2019; 41:1839-1862. [DOI: 10.1016/j.clinthera.2019.06.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/04/2019] [Accepted: 06/25/2019] [Indexed: 01/30/2023]
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Direct Oral Anticoagulants Use in Antiphospholipid Syndrome: Are These Drugs an Effective and Safe Alternative to Warfarin? A Systematic Review of the Literature: Comment. Curr Rheumatol Rep 2019; 19:50. [PMID: 28730526 PMCID: PMC5519642 DOI: 10.1007/s11926-017-0675-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We respond to comments by Dufrost et al. about the RAPS trial, in particular, showing that the trial did achieve its target sample size; pointing out that thrombin potential is not synonymous with overall thrombin generation; confirming that overall, no increased thrombotic risk was evident comparing rivaroxaban with warfarin; and that high-risk patients (28% were triple positive, representative of patients with venous thromboembolism requiring standard-intensity anticoagulation) were included; and clarifying our rationale for using a laboratory surrogate primary outcome measure instead of a clinical one.
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Vadgama TS, Smith A, Bertolaccini ML. Treatment in thrombotic antiphospholipid syndrome: a review. Lupus 2019; 28:1181-1188. [PMID: 31345117 DOI: 10.1177/0961203319864163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Antiphospholipid syndrome an autoimmune disease characterized by thrombosis and/or pregnancy morbidity alongside the presence of antiphospholipid antibodies (aPL). This review evaluates primary and secondary thromboprophylaxis in patients with aPL and thrombotic events. In primary thromboprophylaxis a risk-stratified approach is needed based on aPL, comorbidity with other autoimmune conditions and cardiovascular vascular risk factors. In primary thromboprophylaxis, the efficacy of low-dose aspirin is debatable and requires better-designed controlled studies. So far warfarin has not been shown to improve venous and/or arterial thrombosis incidence in aPL carriers and instead increased safety concerns. The benefit of hydroxychloroquine is inconclusive despite promising data, requiring large, controlled trials. For secondary thromboprophylaxis warfarin seems to be the best option with potential in renal transplant recipients and better efficacy at high intensity, although maintenance of target international normalized ratio needs careful monitoring. Aspirin has not shown to be beneficial, and data on rivaroxaban are limited and contradictory. Despite all data being informative, there are limitations that need to be addressed with robust clinical trials.
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Affiliation(s)
- T S Vadgama
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, King's College London, St Thomas' Hospital, London, UK
| | - A Smith
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, King's College London, St Thomas' Hospital, London, UK
| | - M L Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, King's College London, St Thomas' Hospital, London, UK
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Tektonidou MG, Andreoli L, Limper M, Tincani A, Ward MM. Management of thrombotic and obstetric antiphospholipid syndrome: a systematic literature review informing the EULAR recommendations for the management of antiphospholipid syndrome in adults. RMD Open 2019; 5:e000924. [PMID: 31168416 PMCID: PMC6525610 DOI: 10.1136/rmdopen-2019-000924] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/31/2023] Open
Abstract
Objective To perform a systematic literature review (SLR) informing the European Lmmendations for the management of antiphospholipid syndrome (APS) in adults. Methods A SLR through January 2018 was performed. Research questions were constructed using the Patient, Intervention, Comparator, Outcome (PICO) format. We included data from articles that reported on each relevant intervention. Summary effect estimates were calculated for direct comparison studies that matched the PICO question exactly, and for studies with the relevant intervention and comparator. When meta-analyses were available, we used these estimates. Results From 7534 retrieved articles (+15 from hand searches), 188 articles were included in the review. In individuals with high-risk antiphospholipid antibody (aPL) profile without prior thrombotic or obstetric APS, two meta-analyses showed a protective effect of low-dose aspirin (LDA) against thrombosis. Two randomised controlled trials (RCTs) and three cohort studies showed no additional benefit of treatment with vitamin K antagonists at target international normalised ratio (INR) 3–4 versus INR 2–3 in patients with venous thrombosis. In patients with arterial thrombosis, two RCTs and two cohort studies showed no difference in risk of recurrent thrombosis between the two target INR groups. One open-label trial showed higher rates of thrombosis recurrences in triple aPL-positive patients treated with rivaroxaban than those treated with warfarin. RCTs and cohort studies showed that combination treatment with LDA and heparin was more effective than LDA alone in several types of obstetric APS. SLR results were limited by the indirect evidence and the heterogeneity of patient groups for some treatments, and only a few high-quality RCTs. Conclusion Well-designed studies of homogeneous APS patient populations are needed.
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Affiliation(s)
- Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, University of Athens, Athens, Greece
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marteen Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michael M Ward
- Intramural Research Program, NIAMS/NIH, Bethesda, Maryland, USA
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Pharmacogenetics Biomarkers Predictive of Drug Pharmacodynamics as an Additional Tool to Therapeutic Drug Monitoring. Ther Drug Monit 2019; 41:121-130. [DOI: 10.1097/ftd.0000000000000591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Elsebaie MAT, van Es N, Langston A, Büller HR, Gaddh M. Direct oral anticoagulants in patients with venous thromboembolism and thrombophilia: a systematic review and meta-analysis. J Thromb Haemost 2019; 17:645-656. [PMID: 30690830 DOI: 10.1111/jth.14398] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Indexed: 12/15/2022]
Abstract
Essentials We investigated direct oral anticoagulant (DOAC) use in venous thromboembolism and thrombophilia. A comprehensive search identified 10 studies, 8 of which were included in a meta-analysis. DOACs were overall safe and effective in patients with venous thromboembolism and thrombophilia. Efficacy/safety of DOACs was maintained in low-risk antiphospholipid syndrome patient subgroup. SUMMARY: Background Direct oral anticoagulants (DOACs) are increasingly used in acute and long-term treatment of venous thromboembolism (VTE). However, their role in management of thrombophilia-associated VTE is controversial. Methods Through a comprehensive search on MEDLINE, Cochrane Library, and Clinicaltrials.gov, we identified 10 eligible studies, 8 of which reporting data on 1994 thrombophilia patients were included in a random-effects meta-analysis. Eligible studies were phase 2 to 3 randomized controlled trials comparing DOACs to vitamin K antagonists (VKAs) in patients with VTE, including those with thrombophilia. Results Of eight studies included in meta-analysis, four evaluated rivaroxaban, three dabigatran, and one edoxaban. No results could be obtained on apixaban use. The rates of VTE recurrence (RR, 0.70; 95% CI, 0.34-1.44; I2 = 0%) and major/clinically relevant non-major bleeding events (RR, 0.92; 95% CI, 0.62-1.36; I2 = 23%) were similar between thrombophilia patients treated with DOACs compared to VKAs. Results were comparable to findings in patients without known thrombophilia: RR, 1.02; 95% CI, 0.80-1.30; I2 = 46% for VTE recurrence and RR, 0.72; 95% CI, 0.57-0.90; I2 = 84% for major/clinically relevant non-major bleeding events. Conclusions Rates of VTE recurrence and bleeding events were both low and comparable in patients with various thrombophilias receiving either treatment, suggesting that DOACs are an appropriate treatment option in this population. Due to limited data, it is unclear whether these findings apply to specific subgroups such as high-risk antiphospholipid syndrome, uncommon thrombophilias, or the use of apixaban.
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Affiliation(s)
| | - Nick van Es
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Amelia Langston
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Manila Gaddh
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
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Kargiotis O, Psychogios K, Safouris A, Magoufis G, Zervas PD, Stamboulis E, Tsivgoulis G. The Role of Transcranial Doppler Monitoring in Patients with Multi‐Territory Acute Embolic Strokes: A Review. J Neuroimaging 2019; 29:309-322. [DOI: 10.1111/jon.12602] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
| | | | - Apostolos Safouris
- Stroke UnitMetropolitan Hospital Piraeus Greece
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
| | | | - Paschalis D. Zervas
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
| | | | - Georgios Tsivgoulis
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
- Department of NeurologyThe University of Tennessee Health Science Center Memphis TN
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Yagi S, Nishiyama S, Abe T, Sata M. Recurrent venous thromboembolism after discontinuation of rivaroxaban therapy in a patient with antiphospholipid syndrome. BMJ Case Rep 2019; 12:12/1/bcr-2018-227663. [PMID: 30635311 DOI: 10.1136/bcr-2018-227663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterised by thromboembolic events including venous thromboembolism (VTE) in association with the presence of antiphospholipid antibodies. The standard treatment of VTE historically consists of anticoagulation therapy with warfarin, a vitamin K antagonist. Recently, direct oral anticoagulants, including rivaroxaban have become available for the treatment of VTE. However, the choice of anticoagulant, and the duration of anticoagulation in patients with APS has not been determined yet due to lack of evidence. Here, we report a case of recurrent venous thrombosis after discontinuation of rivaroxaban therapy and avoiding sedentary lifestyle in a patient with APS. We suggest that indefinite anticoagulation therapy might be needed even in low-risk APS cases.
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Affiliation(s)
- Shusuke Yagi
- Shikoku Central Hospital, Shikoku-chuo, Ehime, Japan.,Department of Cardiovascular Medicine, Tokushima University Graduate School of BiomedicalSciences, Tokushima, Japan.,Department of Community Medicine and Human ResourceDevelopment, Tokushima University Graduate School of BiomedicalSciences, Tokushima, Japan
| | | | - Toshio Abe
- Shikoku Central Hospital, Shikoku-chuo, Ehime, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of BiomedicalSciences, Tokushima, Japan
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Skeith L. Anticoagulating patients with high-risk acquired thrombophilias. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:439-449. [PMID: 30504344 PMCID: PMC6246016 DOI: 10.1182/asheducation-2018.1.439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Antiphospholipid syndrome (APS), heparin-induced thrombocytopenia, and paroxysmal nocturnal hemoglobinuria are 3 acquired thrombophilias that carry a high risk of venous and arterial thromboembolism. Management of these conditions has largely included anticoagulation with a vitamin K antagonist after an initial period of a parenteral anticoagulant, for as long as the thrombotic risk is still present. The available evidence for the use of direct oral anticoagulants (DOACs) is limited and primarily consists of case series and cohort studies, which are summarized in this chapter. Randomized trials evaluating DOACs in patients with APS are reviewed. Further research is needed prior to widely adopting DOACs for use in these high-risk acquired thrombophilias; however, there may be selected low-risk subgroups where DOAC use is possible after careful consideration and patient discussion.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada; and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Fleetwood T, Cantello R, Comi C. Antiphospholipid Syndrome and the Neurologist: From Pathogenesis to Therapy. Front Neurol 2018; 9:1001. [PMID: 30534110 PMCID: PMC6275383 DOI: 10.3389/fneur.2018.01001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/06/2018] [Indexed: 12/16/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune antibody-mediated condition characterized by thrombotic events and/or pregnancy morbidity in association with persistent positivity to antiphospholipid antibodies (aPL). The nervous system is frequently affected, as intracranial vessels are the most frequent site of arterial pathology. Over the course of years, many other neurological conditions not included in the diagnostic criteria, have been associated with APS. The pathogenic mechanisms behind the syndrome are complex and not fully elucidated. aPL enhance thrombosis, interfering with different pathways. Nevertheless, ischemic injury is not always sufficient to explain clinical features of the syndrome and immune-mediated damage has been advocated. This may be particularly relevant in the context of neurological complications. The reason why only a subgroup of patients develop non-criteria nervous system disorders and what determines the clinical phenotype are questions that remain open. The double nature, thrombotic and immunologic, of APS is also reflected by therapeutic strategies. In this review we summarize known neurological manifestations of APS, revisiting pathogenesis and current treatment options.
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Affiliation(s)
- Thomas Fleetwood
- Section of Neurology, Department of Translational Medicine University of Eastern Piedmont, Novara, Italy
| | - Roberto Cantello
- Section of Neurology, Department of Translational Medicine University of Eastern Piedmont, Novara, Italy
| | - Cristoforo Comi
- Section of Neurology, Department of Translational Medicine University of Eastern Piedmont, Novara, Italy.,Interdisciplinary Research Centre of Autoimmune Diseases University of Eastern Piedmont, Novara, Italy
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Anticoagulating patients with high-risk acquired thrombophilias. Blood 2018; 132:2219-2229. [DOI: 10.1182/blood-2018-05-848697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/07/2018] [Indexed: 01/19/2023] Open
Abstract
Abstract
Antiphospholipid syndrome (APS), heparin-induced thrombocytopenia, and paroxysmal nocturnal hemoglobinuria are 3 acquired thrombophilias that carry a high risk of venous and arterial thromboembolism. Management of these conditions has largely included anticoagulation with a vitamin K antagonist after an initial period of a parenteral anticoagulant, for as long as the thrombotic risk is still present. The available evidence for the use of direct oral anticoagulants (DOACs) is limited and primarily consists of case series and cohort studies, which are summarized in this chapter. Randomized trials evaluating DOACs in patients with APS are reviewed. Further research is needed prior to widely adopting DOACs for use in these high-risk acquired thrombophilias; however, there may be selected low-risk subgroups where DOAC use is possible after careful consideration and patient discussion.
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Li C, Zhao J, He K, Wu Y, Liu S, Wang Q, Zhao Y. Curative resolution of chronic thromboembolic pulmonary hypertension with pulmonary thromboendarterectomy in primary antiphospholipid syndrome: A case report. Medicine (Baltimore) 2018; 97:e12710. [PMID: 30290671 PMCID: PMC6200469 DOI: 10.1097/md.0000000000012710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe complication of antiphospholipid syndrome (APS). Once diagnosed, the recommendation for the treatment of CTEPH is long-term anticoagulation and pulmonary thromboendarterectomy (PTE). However, cardiac surgeons apply PTE cautiously for these patients, as there is an increased risk of perioperative complications. Here, we present the curative case of a patient with severe APS-associated CTEPH treated with PTE. PATIENT CONCERNS A 29-year-old man presented with chest pain, decreased exercise capacity, dyspnoea, and haemoptysis. DIAGNOSES He was triple positive for antiphospholipid antibodies. Computed tomography pulmonary angiography revealed multiple, recurrent pulmonary embolisms and complete obstruction of the left pulmonary artery. He was diagnosed with APS and CTEPH. INTERVENTIONS After balancing the risk of thrombosis and haemorrhage, the patient underwent PTE. OUTCOMES The patient experienced symptom relief after PTE, and electrocardiography at a six-month follow-up showed a recovery of cardiac structure and pulmonary arterial pressure. LESSONS After evaluating the thrombosis risk at an experienced treatment centre and the application of standard anticoagulation treatment, PTE may be a curative resolution for APS-associated CTEPH.
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Affiliation(s)
- Can Li
- Department of Rheumatology
| | | | - Kun He
- Department of Medicine, Peking Union Medical College Hospital
| | | | - Sheng Liu
- Department of Cardiac Surgery, Fu Wai Hospital, Chinese Academy of Medical Science, Beijing, China
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Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood 2018; 132:1365-1371. [DOI: 10.1182/blood-2018-04-848333] [Citation(s) in RCA: 403] [Impact Index Per Article: 67.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/03/2018] [Indexed: 12/21/2022] Open
Abstract
Publisher's Note: There is a Blood Commentary on this article in this issue.
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Campbell EJ, Clarke AE, Ramsey-Goldman R. Systemic lupus erythematosus: a case-based presentation of renal, neurologic, and hematologic emergencies. Expert Rev Clin Immunol 2018; 14:803-816. [PMID: 30173578 DOI: 10.1080/1744666x.2018.1518132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with systemic manifestations and multiorgan involvement. Although primarily diagnosed, and managed in the outpatient setting, it can occasionally present with life-threatening complications that require rapid assessment and urgent aggressive therapy. Areas covered: In our review, we explore three organ systems that are often affected in SLE, but have the potential to present as medical emergencies; these are the kidney, the central nervous system, and the hematologic system. We take a case-based approach to each clinical scenario, with information given sequentially in order to reflect "real-life" situations where management decisions need to be made with limited information. We review the acute management, pathophysiology, diagnostic approach, and treatment along with a review of the literature, for lupus nephritis presenting as rapidly progressive glomerulonephritis, acute lupus transverse myelitis, and refractory antiphospholipid syndrome. Expert commentary: At the conclusion of each section, we provide an expert commentary regarding each issue, relating to diagnosis, early management, and current evidence behind treatment recommendations.
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Affiliation(s)
- Eric J Campbell
- a Internal Medicine Resident, Department of Medicine, Cumming School of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Ann E Clarke
- b Professor of Medicine, Division of Rheumatology, The Arthritis Society Chair in Rheumatic Diseases, Cumming School of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Rosalind Ramsey-Goldman
- c Solovy Arthritis Research Society Professor of Medicine, Department of Medicine/Rheumatology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
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Pengo V, Denas G. Diagnostics and treatment of thrombotic antiphospholipid syndrome (APS): A personal perspective. Thromb Res 2018; 169:35-40. [PMID: 30007134 DOI: 10.1016/j.thromres.2018.07.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 01/25/2023]
Abstract
Antiphospholipid Syndrome (APS) is a condition characterized by the occurrence of thromboembolic events and/or pregnancy loss combined with one laboratory criterion among Lupus Anticoagulant- LAC, anticardiolipin -aCL, and anti β2-Glycoprotein I -aβ2GPI antibodies. Several hypotheses were put forward to explain the causal role of antibodies in the clinical events but none is fully convincing. Current laboratory diagnosis is based on three tests (LAC, IgG/IgM aβ2GPI and IgG/IgM aCL antibodies). The triple-positive profile (all the three tests positive, same isotype) is associated with a higher risk for thrombosis. The mainstay of therapy in thrombotic APS is anticoagulation, with VKAs being the cornerstone. Low dose aspirin in combination or alone may have a role in arterial thrombosis, and in primary thromboprophylaxis. The Non-Vitamin K Antagonists Oral Anticoagulants (NOACs) role in the therapy of APS is under investigation but not verified. Alternative treatment options including rituximab and eculizumab have been successfully reported in few cases of catastrophic APS.
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Affiliation(s)
- Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Italy.
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Italy
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Sirinvaravong N, Rodriguez Ziccardi MC, Patnaik S, Shah M, Fernandez G, Aliling JN, Rubin A. Nonbacterial thrombotic endocarditis in a patient with primary antiphospholipid syndrome. Oxf Med Case Reports 2018; 2018:omy024. [PMID: 29977578 PMCID: PMC6016692 DOI: 10.1093/omcr/omy024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/09/2018] [Accepted: 04/16/2018] [Indexed: 11/24/2022] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is described in patients with mucin-producing cancers and connective tissue disorders (usually SLE). We report NBTE in the setting of primary antiphospholipid antibody syndrome (APS). A 65-year-old female with APS was incidentally found to have thickened mitral leaflets on transthoracic echocardiogram with no signs of infection. Transesophageal echocardiogram (TEE) showed a mobile mitral mass (1.4 × 0.7 cm) and moderate mitral regurgitation. Differential diagnoses included bacterial endocarditis, NBTE, thrombus or tumor. Given the history of primary APS, the absence of fever and negative blood cultures, NBTE was considered. Low-molecular-weight heparin, hydroxychloroquine and corticosteroid were initiated. Repeat TEE in a week revealed shrinkage of the mass (0.6 × 0.7 cm), indicating an inflammatory nature. Lifelong anticoagulation is indicated regardless of embolism occurrence. Hydroxychloroquine and corticosteroids may have roles in the treatment. Determining and treating the underlying etiology is important.
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Affiliation(s)
| | | | - Soumya Patnaik
- Division of Cardiology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mahek Shah
- Division of Cardiology, Lehigh Valley Healthcare Network, Allentown, PA, USA
| | - Gustavo Fernandez
- Division of Pulmonology, Temple University Hospital, Philadelphia, PA, USA
| | | | - Alexander Rubin
- Division of Cardiology, Pennsylvania Heart and Vascular Group, Jenkintown, Philadelphia PA, USA
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