1
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Sun X, Pan H, Lu H, Song S, Jin C, Pu Y. Diagnostic significance of combined anti-extractable nuclear antigens antibody, anti-cardiolipin antibody and anti-β2-glycoprotein 1 in systemic lupus erythematosus patients. Heliyon 2024; 10:e29230. [PMID: 38617903 PMCID: PMC11015451 DOI: 10.1016/j.heliyon.2024.e29230] [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: 10/16/2023] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/16/2024] Open
Abstract
Objective This study aimed to investigate the diagnostic value of a combination of anti-extractable nuclear antigens (anti-ENA) antibodies, anti-cardiolipin antibodies (ACA), and anti-β2-glycoprotein 1 (anti-β2 GPI) antibodies in patients with systemic lupus erythematosus (SLE). Methods A total of 646 SLE patients diagnosed in our hospital between January 2020 and April 2023 were randomly selected as study subjects, while 2075 non-SLE subjects during the same period were selected as the control group. The levels of anti-extractable nuclear antigen (ENA) antibody, ACA, and anti-β2 GPI antibodies were measured, and their diagnostic value for SLE was analyzed using binary logistic regression and receiver operating characteristic (ROC) analysis. Results The rates of positive anti-RNP, anti-Sm, anti-Sjögren's syndrome (SS-A), and anti-SS-B antibodies in the SLE patient group were significantly higher than those in the control group, with all differences being statistically significant (P < 0.01). The rates of positive ACA, as well as the levels of ACA IgA, ACA IgG, and ACA IgM, were significantly higher in the SLE patients group compared to the control group, with statistically differences (P < 0.05). Similarly, the rates of positive anti-β2 GPI antibodies, anti-β2 GPI antibody IgA, IgG, and IgM, were significantly higher in the SLE patient group compared to the control group, with all differences being statistically significant (P < 0.01). Gender, age, positive anti-JO1 antibodies, positive anti-RNP antibodies, positive anti-SS-A antibodies, positive ACA, high level ACA IgG and ACA IgM, positive anti-β2 GPI antibodies, and high level of anti-β2 GPI antibody IgA were identified as independent risk factors for the development of SLE (P < 0.05). The combined use of age, sex, anti-ENA antibodies, ACA, and anti-β2 GPI antibodies yielded a sensitivity of 82.12% (80.41%-83.71%) and a specificity of 80.03% (76.77%-82.93%) for the diagnosis of SLE. Conclusion The combination of age, sex, anti-ENA antibodies, ACA, and anti-β2 GPI antibodies shows high diagnostic value for SLE and holds potential for clinical application as an auxiliary diagnostic tool for SLE.
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Affiliation(s)
| | | | | | - Shanshan Song
- Department of Clinical Laboratory, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Chengjun Jin
- Department of Clinical Laboratory, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yingye Pu
- Department of Clinical Laboratory, Changhai Hospital, Naval Medical University, Shanghai, China
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2
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Ruzdija D, Bertolo A, Pandya SK, Amaraneni A. A Case Report of Refractory Diffuse Alveolar Hemorrhage as a Complication of Antiphospholipid Syndrome and Review of Its Management. Cureus 2023; 15:e47267. [PMID: 38022217 PMCID: PMC10655834 DOI: 10.7759/cureus.47267] [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: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Diffuse alveolar hemorrhage is a rare complication of antiphospholipid syndrome with high mortality rates. Early diagnosis and treatment with steroids and immunosuppressive agents, along with the achievement of hemostasis and hemodynamic stability, is critical to improving outcomes. This case demonstrates the complexity of managing refractory diffuse alveolar hemorrhage in a 48-year-old woman with antiphospholipid syndrome requiring treatment with high-dose corticosteroids, rituximab, and cyclophosphamide.
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Affiliation(s)
- Denis Ruzdija
- Internal Medicine, University of Arizona, Tucson, USA
| | - Aaron Bertolo
- Internal Medicine, University of Arizona, Tucson, USA
| | | | - Akshay Amaraneni
- Hematology and Oncology, University of Arizona Cancer Center, Tucson, USA
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3
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Gan Y, Zhong X, Zhao Y, Li G, Ye H, Li C. Low dose versus standard dose rituximab for the treatment of antiphospholipid syndrome: A pilot study from a tertiary medical center. Front Immunol 2022; 13:971366. [PMID: 36405743 PMCID: PMC9670802 DOI: 10.3389/fimmu.2022.971366] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/11/2022] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND To investigate the therapeutic effects and safety of low-dose and standard-dose rituximab (RTX) in the treatment of antiphospholipid syndrome (APS). METHODS In this real-world study, we included 22 consecutive patients with APS who received RTX. Standard dose (SD) was defined as an overall dosage of RTX ≥ 1000mg in the induction period, and low dose (LD) was defined as an overall dosage of RTX <1000mg. RESULTS Of included patients, 1 patients died, 2 patients withdrew and 19 patients completed 6-month follow-up. Nine patients received SD-RTX and 13 patients received LD-RTX, and elder patients [LD-RTX vs. SD-RTX: (49.1 ± 15.5) vs. (35.8 ± 12.3) years, p = 0.044] and patients with later-onset [LD-RTX vs. SD-RTX: (46.8 ± 16.3) vs. (31.3 ± 13.6) years, p = 0.029] were more frequently included in LD-RTX than SD-RTX. Following 6 month RTX treatment, 8 patients (42.1%) achieved complete remission, 8 patients (42.1%) achieved partial remission and 3 patients (15.8%) showed no remission. The titers of anticardiolipin antibodies [baseline vs. 6 months: 30.8 (10.7, 90) vs. 19.5 (2.45, 69.10) U/L, p = 0.023] and the levels of erythrocyte sedimentation rate [baseline vs. 6 months: 29 (6, 63) vs. '6 (3, 14) mm/h, p = 0.021] exhibited a significantly decrease in all APS patients. Remission rate and titers of anti-β2-glycoprotein I and lupus anticoagulant did not differ significantly between two groups. CONCLUSION RTX might be a safe and effective option for patients with APS, and low dose confers equal efficacy as standard dose. Further cohort studies are needed to confirm our findings.
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Affiliation(s)
- Yuzhou Gan
- Department of Rheumatology & Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Peking University People’s Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
| | - Xue Zhong
- Department of Pharmacy, Peking University People’s Hospital, Beijing, China
| | - Yawei Zhao
- Department of Rheumatology and Immunology, Luohe Central Hospital, Luohe, Henan, China
| | - Gongming Li
- Department of Rheumatology, Linyi Traditional Chinese Medicine Hospital, Linyi, Shandong, China
| | - Hua Ye
- Department of Rheumatology & Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Peking University People’s Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
| | - Chun Li
- Department of Rheumatology & Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Peking University People’s Hospital, Beijing, China
- Center of Clinical Immunology, Peking University, Beijing, China
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4
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How I treat anticoagulant-refractory thrombotic antiphospholipid syndrome. Blood 2021; 137:299-309. [PMID: 32898856 DOI: 10.1182/blood.2020004942] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 09/02/2020] [Indexed: 12/26/2022] Open
Abstract
The standard treatment of thrombotic antiphospholipid syndrome (APS) is lifelong oral anticoagulation with a vitamin K antagonist (VKA), generally warfarin. A minority of patients with APS rethrombose despite seemingly adequate anticoagulation. These patients are deemed anticoagulant refractory. The management of anticoagulant-refractory APS is largely empirical and extrapolated from other clinically similar situations. Further options include increased VKA anticoagulation intensity or alternative antithrombotic strategies, including low-molecular-weight heparin, fondaparinux, the addition of antiplatelet therapy, and consideration of vascular options. Patients with anticoagulant-refractory thrombotic APS may have APS-associated thrombocytopenia, which necessitates balancing the risk of recurrent thrombosis vs bleeding to achieve adequate anticoagulation. The multiple mechanisms involved in the generation of the thrombotic phenotype in APS suggest that anticoagulation alone may not control thrombosis. Thus, other modalities, including adjunctive treatment (hydroxychloroquine, statins, and vitamin D) for APS-related thrombosis, merit consideration, as do immunomodulatory therapy and complement inhibition. Patients with APS may have coexistent systemic lupus erythematosus, which adds to the complexity of managing their thromboembolic disease. However, with attention to detail and judicious application of the limited data, it is possible to minimize the morbidity resulting from anticoagulant-refractory thrombotic APS. Multicenter studies are required to guide the sequence of interventions and their comparative efficacy in patients with anticoagulant-refractory thrombotic APS.
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Abstract
It is now two decades since Rituximab was first used in the treatment of patients with systemic lupus erythematosus. There have been many challenges but in spite of failing to meet its primary endpoints in two clinical trials it is widely used for many aspects of lupus, its side-effects and the possibility that combining it with Benlysta may be of value. We also consider the proposal that it may provide a useful initial therapy. In this review, we consider the place of Rituximab in the treatment of lupus and anticipate how developments in fully-humanized anti-CD20 monoclonals may well extend the "therapeutic life" of B-cell depletion as a viable treatment option.
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Affiliation(s)
- Maria Leandro
- Centre for Rheumatology, Division of Medicine, University College London, London, UK.,Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - David A Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK.,Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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6
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You Y, Shi C, Zhou Z, Wang F, Sun Y, Teng J, Liu H, Cheng X, Su Y, Shi H, Yang C, Ye J. Rituximab in thrombotic primary antiphospholipid syndrome: a pilot study from a single centre in China. Ann Rheum Dis 2021; 80:820-822. [PMID: 33452001 DOI: 10.1136/annrheumdis-2020-219303] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Yijun You
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ce Shi
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuochao Zhou
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Sun
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Honglei Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobing Cheng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yutong Su
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junna Ye
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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7
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Cohen H, Cuadrado MJ, Erkan D, Duarte-Garcia A, Isenberg DA, Knight JS, Ortel TL, Rahman A, Salmon JE, Tektonidou MG, Williams DJ, Willis R, Woller SC, Andrade D. 16th International Congress on Antiphospholipid Antibodies Task Force Report on Antiphospholipid Syndrome Treatment Trends. Lupus 2020; 29:1571-1593. [PMID: 33100166 PMCID: PMC7658424 DOI: 10.1177/0961203320950461] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 07/24/2020] [Indexed: 12/13/2022]
Abstract
Antiphospholipid syndrome (APS), an acquired autoimmune thrombophilia, is characterised by thrombosis and/or pregnancy morbidity in association with persistent antiphospholipid antibodies. The 16th International Congress on Antiphospholipid Antibodies Task Force on APS Treatment Trends reviewed the current status with regard to existing and novel treatment trends for APS, which is the focus of this Task Force report. The report addresses current treatments and developments since the last report, on the use of direct oral anticoagulants in patients with APS, antiplatelet agents, adjunctive therapies (hydroxychloroquine, statins and vitamin D), targeted treatment including rituximab, belimumab, and anti-TNF agents, complement inhibition and drugs based on peptides of beta-2-glycoprotein I. In addition, the report summarises potential new players, including coenzyme Q10, adenosine receptor agonists and adenosine potentiation. In each case, the report provides recommendations for clinicians, based on the current state of the art, and suggests a clinical research agenda. The initiation and development of appropriate clinical studies requires a focus on devising suitable outcome measures, including a disease activity index, an optimal damage index, and a specific quality of life index.
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Affiliation(s)
- Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University
College London, London, UK
- University College London Hospitals NHS Foundation Trust,
London, UK
| | - Maria J Cuadrado
- Rheumatology Department, Clinica Universidad de Navarra, Madrid,
Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital
for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Ali Duarte-Garcia
- Division of Rheumatology, Department of Internal Medicine, Mayo
Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health
Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Isenberg
- University College London Hospitals NHS Foundation Trust,
London, UK
- Centre for Rheumatology, Division of Medicine, University
College London, London, UK
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor,
Michigan, USA
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine, and Department
of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Anisur Rahman
- Centre for Rheumatology, Division of Medicine, University
College London, London, UK
| | - Jane E Salmon
- Division of Rheumatology, Hospital for Special surgery, Weill
Cornell Medicine, New York, NY, USA
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, National
and Kapodistrian University of Athens, Athens, Greece
| | - David J Williams
- University College London Hospitals NHS Foundation Trust,
London, UK
- UCL EGA Institute for Women’s Health, University College
London, London, UK
| | - Rohan Willis
- Antiphospholipid Standardization Laboratory, University of
Texas Medical Branch, Galveston, TX, USA
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray
UT; Division of General Internal Medicine, University of Utah School of
Medicine, Salt Lake City, UT, USA
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8
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Radin M, Cecchi I, Rubini E, Foddai SG, Barinotti A, Menegatti E, Roccatello D, Sciascia S. Treatment of antiphospholipid syndrome. Clin Immunol 2020; 221:108597. [PMID: 32961331 DOI: 10.1016/j.clim.2020.108597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/05/2020] [Accepted: 09/15/2020] [Indexed: 12/11/2022]
Abstract
Antiphospholipid syndrome (APS) is the most common acquired thrombophilia. The clinical manifestations of APS are mainly vascular thrombosis (venous and/or arterial) and/or recurrent pregnancy morbidity with the concomitant persistent presence of antiphospholipid antibodies (aPL). Therefore, the goals of the treatment of patients with APS are reducing the pregnancy morbidity and/or the prevention of thrombotic events during the follow-up. Optimal treatment of APS has long been discussed, due to the heterogeneity of the clinical manifestations and the consequent plurality in the medical specialties involved in managing this condition. This review summarizes the available evidence on primary thromboprophylaxis in aPL-positive individuals with no prior thrombotic events, secondary prophylaxis in patients with positive history for thrombotic events, the management of refractory or difficult cases and the current strategies for the management of APS during pregnancy.
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Affiliation(s)
- Massimo Radin
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Silvia Grazietta Foddai
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Alice Barinotti
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Elisa Menegatti
- School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Italy; Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Italy.
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9
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Cohen H, Sayar Z, Efthymiou M, Gaspar P, Richards T, Isenberg D. Management of anticoagulant-refractory thrombotic antiphospholipid syndrome. LANCET HAEMATOLOGY 2020; 7:e613-e623. [PMID: 32735839 DOI: 10.1016/s2352-3026(20)30116-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/27/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
Abstract
Lifelong anticoagulation with warfarin or alternative vitamin K antagonist is the standard anticoagulant treatment for thrombotic antiphospholipid syndrome. Anticoagulant-refractory thrombotic antiphospholipid syndrome can be broadly defined as breakthrough thrombosis while on standard oral anticoagulation treatment and its management is a major challenge given the serious nature of the thrombotic disease observed, which has become refractory to oral anticoagulation. The factors (genetic and cellular) that cause anticoagulant-refractory thrombotic antiphospholipid syndrome are now better understood. However, efforts to use this greater understanding have not yet transformed the capacity to treat it successfully in many patients. In this Viewpoint, we review the factors that are likely to be contributing to the cause of this syndrome and consider how they might be modified or inhibited. We also discuss management, including general strategies to minimise thrombotic risk, intensification of anticoagulation, addition of an antiplatelet agent, adjunctive treatment for thrombosis, immunomodulatory therapy, complement inhibition, vascular options, and future potential therapeutic targets.
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Affiliation(s)
- Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK; Haemostasis Research Unit, Department of Haematology, University College London, London, UK.
| | - Zara Sayar
- 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
| | - Pedro Gaspar
- Department of Internal Medicine, Hospital of Santa Maria, Lisbon, Portugal
| | - Toby Richards
- Department of Vascular Surgery, University of Western Australia, Perth, WA, Australia
| | - David Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Rheumatology, Division of Medicine, University College London, London, UK
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10
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Lorenzo-Vizcaya A, Fasano S, Isenberg DA. Bruton's Tyrosine Kinase Inhibitors: A New Therapeutic Target for the Treatment of SLE? Immunotargets Ther 2020; 9:105-110. [PMID: 32582577 PMCID: PMC7276208 DOI: 10.2147/itt.s240874] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/19/2020] [Indexed: 12/30/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with a complex pathogenesis, which presents a great variability in its presentation and can affect almost all organs and systems. Multiple therapeutic targets have been discovered recently, but there also have been failed attempts to treat SLE using biologic agents. Bruton’s tyrosine kinase (BTK) is a cytoplasmic tyrosine kinase expressed in several types of cells of hematopoietic origin which participate in both innate and adaptive immunity. Ibrutinib, a BTK inhibitor, is approved for the treatment of several B cell malignancies, including some types of lymphoma and leukemia. As BTK is expressed on several immune cell types, the mechanism of action of BTK also suggests the use of BTK inhibitors in the treatment of autoimmune diseases. In this review, we will summarize what is known and what has been published so far about the treatment of mouse models of SLE and the human disease, using BTK inhibitors.
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Affiliation(s)
- Ana Lorenzo-Vizcaya
- Department of Internal Medicine, Hospital Universitario De Ourense, Ourense, Spain
| | - Serena Fasano
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Campania L. Vanvitelli, Naples, Italy
| | - David A Isenberg
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
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11
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van den Hoogen LL, van Laar JM. Targeted therapies in systemic sclerosis, myositis, antiphospholipid syndrome, and Sjögren's syndrome. Best Pract Res Clin Rheumatol 2020; 34:101485. [PMID: 32067925 DOI: 10.1016/j.berh.2020.101485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Targeted therapies using biological disease-modifying antirheumatic drugs (bDMARDs) and small molecule synthetic drugs have revolutionized rheumatological practice. Initially developed for the treatment of immune arthritis (rheumatoid arthritis, psoriatic arthritis, and spondylarthritis), both bDMARDs and small molecule synthetic drugs are now increasingly entering the space of connective tissue disease (CTD) treatment. Recent clinical trial data in systemic sclerosis (SSc) have been particularly encouraging with positive effects on outcomes having been observed with nintedanib preventing the decline of lung function in patients with SSc-related interstitial lung disease. Randomized trials targeting B-cells by rituximab in primary Sjogren's syndrome have led to mixed results. Novel strategies to target B-cells in primary Sjögren's syndrome including ianalumab and belimumab are underway and will hopefully result in clear treatment effects. Inflammatory idiopathic myositis (polymyositis (PM) and dermatomyositis (DM)) and antiphospholid syndrome are proving to be more difficult to tackle but are nonetheless the subject of ongoing studies. To what extent new compounds can replace more traditional immunosuppressive drugs remains to be determined, but if the experience in immune arthritis has taught us anything it is that combination therapy may be the way to go.
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Affiliation(s)
- Lucas L van den Hoogen
- Dept of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht University, the Netherlands.
| | - Jacob M van Laar
- Dept of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht University, the Netherlands.
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12
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Dobrowolski C, Erkan D. Treatment of antiphospholipid syndrome beyond anticoagulation. Clin Immunol 2018; 206:53-62. [PMID: 29510235 DOI: 10.1016/j.clim.2018.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/02/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder marked by thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). At the present time, treatment is primarily focused on anticoagulation. However, there is increasing awareness of the mechanisms involved in APS pathogenesis, which has led to the trial of novel therapies targeting those mechanisms. Following a brief review of the etiopathogenesis of and current management strategies in APS, this paper focuses on the evidence for these potential, targeted APS treatments, e.g., hydroxychloroquine, statins, rituximab, belimumab, eculizumab, defibrotide, sirolimus, and peptide therapy.
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Affiliation(s)
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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13
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Wincup C, Ioannou Y. The Differences Between Childhood and Adult Onset Antiphospholipid Syndrome. Front Pediatr 2018; 6:362. [PMID: 30542645 PMCID: PMC6277799 DOI: 10.3389/fped.2018.00362] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/08/2018] [Indexed: 12/12/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a rare autoimmune disease of unknown etiology that represents a leading cause of acquired thromboembolism and recurrent miscarriage. It is characterized by the persistent elevated presence of pathogenic antiphospholipid auto-antibodies directed against cardiolipin, ß2-glycoprotein-I, and/or a positive lupus anticoagulant test. As with many autoimmune disorders, the pathogenesis of APS is believed to be the result of a complex interaction between environmental triggers and genetic predisposition. Although more common in adults, APS occasionally manifests in the neonatal period and throughout childhood. Adut-onset APS classification criteria are poorly validated to the pediatric population (in which pregnancy related complications are seldom seen) and as a result, assessment of the prevalence of the disease in childhood is difficult. Thromboembolic events seen in children include deep venous thrombosis in addition to stroke and pulmonary embolism, which can lead to significant long-term disability. The disease can be classified as either primary (when occurring in isolation) or secondary, in which the disease is diagnosed in the context of another underlying disease, most commonly systemic lupus erythematosus. A variety of laboratory and clinical difference are seen between pediatric and adult-onset APS. The marked female predominance seen in adult-onset disease is less evident in childhood where the gender split is more evenly spread. In addition, children with APS are at a higher risk of recurrent thromboembolism than adults. The treatment of childhood-onset APS is challenging due to a lack of large-scale prospective studies in the pediatric population. Therapeutic options are often based upon treatment guidelines that have been based upon literature from the adult-onset form of the disease. In the majority of cases, treatment is focused on the prevention of further thrombosis through treatment with long-term anti-coagulation therapy. The evidence for the use of antiplatelet agents (such as aspirin) and hydroxychloroquine is inconclusive. It is important to remember that anti-coagulation can have significant lifestyle implications for the child with APS and it is essential to consider potential implications relating to school and recreational activities, with contact sports often discouraged due to the increased risk of bleeding.
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Affiliation(s)
- Chris Wincup
- Department of Rheumatology, University College London, London, United Kingdom.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, United Kingdom
| | - Yiannis Ioannou
- Department of Rheumatology, University College London, London, United Kingdom.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, United Kingdom
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Gracia-Tello B, Isenberg D. Kidney disease in primary anti-phospholipid antibody syndrome. Rheumatology (Oxford) 2017; 56:1069-1080. [PMID: 27550302 DOI: 10.1093/rheumatology/kew307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Indexed: 12/19/2022] Open
Abstract
APS is an autoimmune disease defined by the presence of arterial or venous thrombotic events and/or pregnancy morbidity in patients who test positive for aPL. APS can be isolated (primary APS) or associated with other autoimmune diseases. The kidney is a major target organ in APS, and renal thrombosis can occur at any level within the vasculature of the kidney (renal arteries, intrarenal vasculature and renal veins). Histological findings vary widely, including ischaemic glomeruli and thrombotic lesions without glomerular or arterial immune deposits on immunofluorescence. Renal involvement in patients with definite APS is treated with long-term anticoagulants as warfarin, but new treatments are being tried. The aim of this article is to review the links between primary APS and kidney disease.
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Affiliation(s)
| | - David Isenberg
- Centre for Rheumatology, University College London Hospitals, London, UK
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Weindel CG, Richey LJ, Mehta AJ, Shah M, Huber BT. Autophagy in Dendritic Cells and B Cells Is Critical for the Inflammatory State of TLR7-Mediated Autoimmunity. THE JOURNAL OF IMMUNOLOGY 2016; 198:1081-1092. [PMID: 28031336 DOI: 10.4049/jimmunol.1601307] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/21/2016] [Indexed: 12/22/2022]
Abstract
Individuals suffering from autoimmune disorders possess a hyperactive cellular phenotype where tolerance to self-antigens is lost. Autophagy has been implicated in both the induction and prevention of autoimmunity, and modulators of this cellular recycling process hold high potential for the treatment of autoimmune diseases. In this study, we determine the effects of a loss of autophagy in dendritic cells (DCs), as well as both B cells and DCs, in a TLR7-mediated model of autoimmunity, similar to systemic lupus erythematosus, where both cell types are critical for disease. Although a loss of DC autophagy slowed disease, the combined loss of autophagy in both cell types resulted in a lethal sepsis-like environment, which included tissue inflammation and hyperproduction of inflammasome-associated cytokines. Ablation of B cell signaling reversed this phenotype, indicating that activation of these cells is an essential step in disease induction. Thus, autophagy plays a dichotomous role in this model of disease.
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Affiliation(s)
- Chi G Weindel
- Program in Genetics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA 02111
| | - Lauren J Richey
- Division of Laboratory Animal Medicine, Tufts University, Boston, MA 02111; and
| | - Abhiruchi J Mehta
- Department of Integrative Physiology and Pathobiology, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA 02111
| | - Mansi Shah
- Department of Integrative Physiology and Pathobiology, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA 02111
| | - Brigitte T Huber
- Program in Genetics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA 02111; .,Department of Integrative Physiology and Pathobiology, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA 02111
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Abstract
Antiphospholipid syndrome (APS) is a hypercoagulable state characterized by arterial and venous thromboses and pregnancy morbidity in the presence of antiphospholipid antibodies. Although warfarin remains the main therapeutic choice in APS, there is still concern about its efficacy, safety, and patient compliance. Patients with refractory APS to conventional therapy as well as patients with non-classical manifestations of APS may have alternative treatment approaches. APS pathogenesis has been further elucidated over the past years identifying new molecules as potential new treatment targets. This review summarizes available data from in vitro and animal models and clinical studies on the role of new potential treatment approaches including new oral anticoagulants and immunoregulatory agents: direct thrombin or factor Xa inhibitors, hydroxychloroquine, statins, B cell inhibition, complement inhibition, peptide therapy, nuclear factor κB and p38 mitogen-activated kinase inhibitors, defibrotide, abciximab, mTOR inhibitor, and other potential targets. Large multicenter prospective studies of well-characterized APS patients are needed to assess the efficacy and safety profile of these potential treatment alternatives.
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Affiliation(s)
- Danieli Andrade
- Rheumatology Department, University of São Paulo, Av. Dr. Arnaldo 455, Third Floor, Room 3109, São Paulo, Brazil
| | - Maria Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Programme, National and Kapodistrian University of Athens, Athens, Greece.
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17
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Why are kids with lupus at an increased risk of cardiovascular disease? Pediatr Nephrol 2016; 31:861-83. [PMID: 26399239 DOI: 10.1007/s00467-015-3202-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 08/14/2015] [Accepted: 08/25/2015] [Indexed: 01/12/2023]
Abstract
Juvenile-onset systemic lupus erythematosus (SLE) is an aggressive multisystem autoimmune disease. Despite improvements in outcomes for adult patients, children with SLE continue to have a lower life expectancy than adults with SLE, with more aggressive disease, a higher incidence of lupus nephritis and there is an emerging awareness of their increased risk of cardiovascular disease (CVD). In this review, we discuss the evidence for an increased risk of CVD in SLE, its pathogenesis, and the clinical approach to its management.
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Rodriguez-Pintó I, Santacreu I, Cervera R, Espinosa G. What is the best strategy in treating catastrophic antiphospholipid syndrome? ACTA ACUST UNITED AC 2015. [DOI: 10.2217/ijr.15.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Rodríguez-Pintó I, Cervera R, Espinosa G. Rituximab and its therapeutic potential in catastrophic antiphospolipid syndrome. Ther Adv Musculoskelet Dis 2015; 7:26-30. [PMID: 25649844 DOI: 10.1177/1759720x14554793] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The catastrophic antiphospholipid syndrome (CAPS) is characterized by thrombosis in more than three organs or systems developing over a short period of time. Despite conventional treatment with a combination of anticoagulation plus corticosteroids plus plasma exchange, and/or intravenous immunoglobulin, mortality remains high and some patients suffer from recurrent CAPS episodes. In selected patients, new therapies such as rituximab may be a treatment option. In this review, the rationale for using rituximab in CAPS is discussed.
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Affiliation(s)
- Ignasi Rodríguez-Pintó
- Department of Autoimmune Diseases, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, Barcelona, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, Barcelona, Spain
| | - Gerard Espinosa
- Servei de Malalties Autoimmunes, Hospital Clínic, Villarroel 170, 08036-Barcelona, Catalonia, Spain
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20
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Ugarte A, Ruiz Irastorza G. [Rituximab in antiphospholipid syndrome: always, never, sometimes?]. Med Clin (Barc) 2015; 144:115-7. [PMID: 25148947 DOI: 10.1016/j.medcli.2014.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/10/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Amaia Ugarte
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, BioCruces Health Research Institute, Hospital Universitario Cruces, Universidad del País Vasco/Euskal Herriko Unibertsitatea, Barakaldo, Bizkaia, España
| | - Guillermo Ruiz Irastorza
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, BioCruces Health Research Institute, Hospital Universitario Cruces, Universidad del País Vasco/Euskal Herriko Unibertsitatea, Barakaldo, Bizkaia, España.
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Abstract
Systemic lupus erythematosus is a remarkable and challenging disorder. Its diversity of clinical features is matched by the complexity of the factors (genetic, hormonal, and environmental) that cause it, and the array of autoantibodies with which it is associated. In this Seminar we reflect on changes in its classification criteria; consider aspects of its more serious clinical expression; and provide a brief review of its aetiopathogenesis, major complications, coping strategies, and conventional treatment. Increased understanding of the cells and molecules involved in the development of the diseases has encouraged the identification of new, better targeted biological approaches to its treatment. The precise role of these newer therapies remains to be established.
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Affiliation(s)
| | - Grainne Murphy
- Centre for Rheumatology, Department of Medicine, University College London Hospital, London, UK
| | - David Isenberg
- Centre for Rheumatology, Department of Medicine, University College London Hospital, London, UK.
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22
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Schmidt E, Goebeler M. CD20-directed therapy in autoimmune diseases involving the skin: role of rituximab. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.3.3.259] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Furtado J, Isenberg DA. Reprint of: B cell elimination in systemic lupus erythematosus. Clin Immunol 2013; 148:344-58. [DOI: 10.1016/j.clim.2013.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 11/15/2012] [Indexed: 11/28/2022]
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Furtado J, Isenberg DA. B cell elimination in systemic lupus erythematosus. Clin Immunol 2012; 146:90-103. [PMID: 23280492 DOI: 10.1016/j.clim.2012.11.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 11/12/2012] [Accepted: 11/15/2012] [Indexed: 10/27/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder with a worldwide distribution, potentially life-threatening with considerable morbidity. The elimination of pathogenic B cells has emerged as a rational therapeutic option. Many open label studies have reported encouraging results in which clinical and serological remission have invariably been described, often enabling the reduction of steroid and immunosuppressive treatment. However, the results from randomized controlled studies have been disappointing and several questions remain to be answered. In this review we will focus on results of B cell direct depletion in the treatment of patients with systemic lupus erythematosus.
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Affiliation(s)
- João Furtado
- Department of Internal Medicine, Egas Moniz Hospital, Lisbon, Portugal.
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25
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Aringer M, Burkhardt H, Burmester GR, Fischer-Betz R, Fleck M, Graninger W, Hiepe F, Jacobi AM, Kötter I, Lakomek HJ, Lorenz HM, Manger B, Schett G, Schmidt RE, Schneider M, Schulze-Koops H, Smolen JS, Specker C, Stoll T, Strangfeld A, Tony HP, Villiger PM, Voll R, Witte T, Dörner T. Current state of evidence on 'off-label' therapeutic options for systemic lupus erythematosus, including biological immunosuppressive agents, in Germany, Austria and Switzerland--a consensus report. Lupus 2011; 21:386-401. [PMID: 22072024 DOI: 10.1177/0961203311426569] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Systemic lupus erythematosus (SLE) can be a severe and potentially life-threatening disease that often represents a therapeutic challenge because of its heterogeneous organ manifestations. Only glucocorticoids, chloroquine and hydroxychloroquine, azathioprine, cyclophosphamide and very recently belimumab have been approved for SLE therapy in Germany, Austria and Switzerland. Dependence on glucocorticoids and resistance to the approved therapeutic agents, as well as substantial toxicity, are frequent. Therefore, treatment considerations will include 'off-label' use of medication approved for other indications. In this consensus approach, an effort has been undertaken to delineate the limits of the current evidence on therapeutic options for SLE organ disease, and to agree on common practice. This has been based on the best available evidence obtained by a rigorous literature review and the authors' own experience with available drugs derived under very similar health care conditions. Preparation of this consensus document included an initial meeting to agree upon the core agenda, a systematic literature review with subsequent formulation of a consensus and determination of the evidence level followed by collecting the level of agreement from the panel members. In addition to overarching principles, the panel have focused on the treatment of major SLE organ manifestations (lupus nephritis, arthritis, lung disease, neuropsychiatric and haematological manifestations, antiphospholipid syndrome and serositis). This consensus report is intended to support clinicians involved in the care of patients with difficult courses of SLE not responding to standard therapies by providing up-to-date information on the best available evidence.
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Affiliation(s)
- M Aringer
- Rheumatology, Medicine III, University Medical Center TU Dresden, Germany.
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Sciascia S, Naretto C, Rossi D, Bazzan M, Roccatello D. Treatment-induced downregulation of antiphospholipid antibodies: effect of rituximab alone on clinical and laboratory features of antiphospholipid syndrome. Lupus 2011; 20:1106-1108. [DOI: 10.1177/0961203311400115] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- S Sciascia
- Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare (CMID), SC a Direzione Universitaria di Immunologia Clinica, Università di Torino, Turin, Italy
| | - C Naretto
- Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare (CMID), SC a Direzione Universitaria di Immunologia Clinica, Università di Torino, Turin, Italy
| | - D Rossi
- Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare (CMID), SC a Direzione Universitaria di Immunologia Clinica, Università di Torino, Turin, Italy
| | - M Bazzan
- SSD Ematologia, Dipartimento di Malattie Rare, Immunologiche, Ematologiche ed Immunoematologiche, Università di Torino, Turin, Italy
| | - D Roccatello
- Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare (CMID), SC a Direzione Universitaria di Immunologia Clinica, Università di Torino, Turin, Italy
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Long-lived autoreactive plasma cells drive persistent autoimmune inflammation. Nat Rev Rheumatol 2011; 7:170-8. [DOI: 10.1038/nrrheum.2011.1] [Citation(s) in RCA: 253] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Cervera R, Espinosa G. Antiphospholipid syndrome: long-time research on pathogenic mechanisms has finally lead to new therapeutic strategies. Expert Opin Ther Targets 2010; 14:1279-82. [DOI: 10.1517/14728222.2010.530900] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pericleous C, Ioannou Y. New therapeutic targets for the antiphospholipid syndrome. Expert Opin Ther Targets 2010; 14:1291-9. [PMID: 20874375 DOI: 10.1517/14728222.2010.524207] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD The antiphospholipid syndrome (APS) is an autoimmune condition whereby pathogenic antiphospholipid antibodies (aPL) cause vascular thrombosis and/or recurrent miscarriage, and carries a high burden of morbidity and mortality. Currently the only proven treatment is long-term anticoagulation, which is not effective in all patients and carries risk of haemorrhage. AREAS COVERED IN THIS REVIEW Novel therapeutic targets that are currently being explored for APS in order to address the unmet needs of better, safer and ideally targeted therapy. These include B cell depletion, new-generation anticoagulants, interfering with aPL cell-mediated activation of endothelial cells and platelets both at the cell surface level and intracellularly, targeting components of the complement system and the novel concept of using decoy peptides to target only the pathogenic sub-population of aPL. WHAT THE READER WILL GAIN An overview of the potential targets and rationale underpinning them. TAKE HOME MESSAGE Though current options remain limited for the treatment of APS, the future holds much promise with the identification of multiple targets, many of which are currently being explored. The challenge will be to undertake carefully designed prospective multi-centre trials to generate the evidence necessary to support integration of such candidates into clinical practice.
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Affiliation(s)
- Charis Pericleous
- Centre for Rheumatology Research, University College London, Division of Medicine, London, UK
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Favas C, Isenberg DA. B-cell-depletion therapy in SLE--what are the current prospects for its acceptance? Nat Rev Rheumatol 2010; 5:711-6. [PMID: 19946298 DOI: 10.1038/nrrheum.2009.218] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Analogous to the successful introduction of biologic agents to treat rheumatoid arthritis, it was widely envisaged that similar successful studies would follow in systemic lupus erythematosus (SLE), as much was known about the etiopathogenesis of the disease and appropriate agents to block the key cells and molecules were available. The reality, however, has been different. The failure of rituximab, a monoclonal antibody that induces B-cell depletion, to meet its primary and secondary end points in trials of nonrenal SLE (EXPLORER) and renal (LUNAR) lupus nephritis has been disappointing given the success reported in many open-label studies. Concluding that B-cell-depletion therapy is not effective in SLE seems rather extreme. Further analysis of the as-yet unpublished results and their comparison with data from published studies might provide insight into whether B-cell depletion will eventually be accepted as a useful approach for the treatment of SLE.
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Affiliation(s)
- Catarina Favas
- Curry Cabral Hospital, Internal Medicine Department, Lisbon, Portugal
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Lu LJ, Wallace DJ, Navarra SV, Weisman MH. Lupus Registries: Evolution and Challenges. Semin Arthritis Rheum 2010; 39:224-45. [DOI: 10.1016/j.semarthrit.2008.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 08/07/2008] [Accepted: 08/25/2008] [Indexed: 11/27/2022]
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Tew GW, Rabbee N, Wolslegel K, Hsieh HJ, Monroe JG, Behrens TW, Brunetta PG, Keir ME. Baseline autoantibody profiles predict normalization of complement and anti-dsDNA autoantibody levels following rituximab treatment in systemic lupus erythematosus. Lupus 2009; 19:146-57. [PMID: 19946034 DOI: 10.1177/0961203309350752] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
B cells are thought to play a major role in the pathogenesis of systemic lupus erythematosus (SLE). Rituximab (RTX), a chimeric anti-CD20 mAb, effectively depletes CD20( +) peripheral B cells. Recent results from EXPLORER, a placebo-controlled trial of RTX in addition to aggressive prednisone and immunosuppressive therapy, showed similar levels of clinical benefit in patients with active extra-renal SLE despite effective B cell depletion. We performed further data analyses to determine whether significant changes in disease activity biomarkers occurred in the absence of clinical benefit. We found that RTX-treated patients with baseline autoantibodies (autoAbs) had decreased anti-dsDNA and anti-cardiolipin autoAbs and increased complement levels. Patients with anti-dsDNA autoAb who lacked baseline RNA binding protein (RBP) autoAbs showed increased complement and decreased anti-dsDNA autoAb in response to RTX. Other biomarkers, such as baseline BAFF levels or IFN signature status did not predict enhanced effects of RTX therapy on complement or anti-dsDNA autoAb levels. Finally, platelet levels normalized in RTX-treated patients who entered the study with low baseline counts. Together, these findings demonstrate clear biologic activity of RTX in subsets of SLE patients, despite an overall lack of incremental clinical benefit with RTX in the EXPLORER trial.
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Affiliation(s)
- G W Tew
- Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080-4990, USA
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Hokama Y, Campora CE, Hara C, Kuribayashi T, Le Huynh D, Yabusaki K. Anticardiolipin antibodies in the sera of patients with diagnosed chronic fatigue syndrome. J Clin Lab Anal 2009; 23:210-2. [PMID: 19623655 DOI: 10.1002/jcla.20325] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Examination of anticardiolipin antibodies (ACAs) in the sera of patients clinically diagnosed with chronic fatigue syndrome (CFS) using an enzyme-linked immunoassay procedure demonstrated the presence of immunoglobulin M isotypes in 95% of CFS serum samples tested. The presence of immunoglobulin G and immunoglobulin A isotypes were also detected in a subset of the samples. Future studies will focus on elucidating whether alterations to mitochondrial inner membranes and/or metabolic functions play a possible role in the expression of ACAs.
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Affiliation(s)
- Yoshitsugi Hokama
- Department of Pathology, John A. Burns School of Medicine, University of Hawaii at Mânoa, Honolulu, Hawaii 96822, USA
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Saha AK, D'Cruz D. New potential therapies for the treatment of antiphospholipid syndrome. Expert Opin Ther Pat 2009; 19:13-22. [DOI: 10.1517/13543770802608048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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37
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Jeffery RC, Narshi CB, Isenberg DA. Prevalence, serological features, response to treatment and outcome of critical peripheral ischaemia in a cohort of lupus patients. Rheumatology (Oxford) 2008; 47:1379-83. [PMID: 18586769 DOI: 10.1093/rheumatology/ken210] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study addresses the issue of risk factors and management of critical peripheral ischaemia (CPI) and gangrene in SLE and proposes rituximab as a novel therapy. METHOD We conducted a retrospective study of 485 patients with SLE attending a UK tertiary referral centre, followed up over 27 yrs. Demographics, clinical features, serological features, treatment and outcome data were assessed. RESULTS Seven out of 485 patients (1.4%) had evidence of gangrene or CPI with onset at any stage of SLE disease from presenting feature to 27 yrs after SLE onset, aPL and LAC were over-represented in the CPI patients. All had active SLE at the time of CPI. All seven were treated with intravenous (IV) epoprostenol infusion and aPL-positive patients were anti-coagulated. One patient failed to respond to this treatment and to IV calcitonin gene-related peptide but responded to B-cell depletion therapy using rituximab. Five out of the seven patients suffered digit loss with auto-amputation. CONCLUSION CPI is a rare but potentially devastating complication of SLE associated with aPL, LAC and active SLE. B-cell depletion therapy with rituximab may be an option in severe ischaemia not improving with IV epoprostenol.
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Affiliation(s)
- R C Jeffery
- Royal Free and University College Medical School, University College London Division of Medicine, Centre for Rheumatology Research, Room 331, 3rd floor, Windeyer Building, 46 Cleveland Street, London W1T 4JF, UK
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