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Chighizola CB, Andreoli L, Gerosa M, Tincani A, Ruffatti A, Meroni PL. The treatment of anti-phospholipid syndrome: A comprehensive clinical approach. J Autoimmun 2018; 90:1-27. [PMID: 29449131 DOI: 10.1016/j.jaut.2018.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/06/2018] [Indexed: 01/02/2023]
Abstract
Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Allergology, Clinical Immunology and Rheumatology, Piazzale Brescia 20, 20149, Milan, Italy.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Department of Rheumatology, ASST Istituto Gaetano Pini & CTO, Piazza Cardinal Ferrari, 1 20122, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy
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Beneventi F, Badulli C, Locatelli E, Caporali R, Ramoni V, Cavagnoli C, Simonetta M, Garbin G, Tinelli C, Alpini C, Montecucco C, Martinetti M, Spinillo A. Soluble HLA-G in pregnancies complicated by autoimmune rheumatic diseases. J Reprod Immunol 2015; 110:67-73. [PMID: 26042897 DOI: 10.1016/j.jri.2015.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 04/16/2015] [Accepted: 04/27/2015] [Indexed: 11/30/2022]
Abstract
Autoimmune rheumatic diseases in pregnancies are associated with increased adverse obstetric outcomes. We compared maternal soluble human leucocyte antigen-G (sHLA-G) blood levels in subjects with a rheumatic disease preexisting pregnancy and unaffected controls. Third-trimester blood maternal sHLA-G concentrations were significantly higher in subjects with rheumatic diseases than in controls (mean 93.1ng/ml [SD 42.1] vs 58.1ng/ml [SD 96.3], p=0.003). Cord blood sHLA-G concentrations were significantly higher in rheumatic disease than in those born to control mothers (median 41.2ng/ml [IQR: 3.3-44.0] vs 17.9ng/ml [IQR: 17.2-88.1], p=0.007). A strict positive correlation (r=0.88, p<0.001) was found between the maternal and fetal titers of ANA autoantibodies as well as between maternal and fetal sHLAG circulating levels (r=0.58 and r=0.67, respectively, for controls and cases, p<0.001). Maternal s-HLA-G blood concentrations were significantly higher in subjects with rheumatic disease DEL/DEL homozygous for a polymorphism of the 3' untranslated regulatory region of HLA-G (HLA-G 14bp) than in the corresponding healthy controls (mean values 141.5ng/ml [SD: 166] vs 54.2ng/ml [SD: 35], p=0.009). Increasing maternal and cord blood levels of s-HLA-G concentrations among pregnant subjects with rheumatic diseases compared with controls suggest that autoimmune diseases prompt a maternal and fetal immune response that favors pregnancy immune tolerance.
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Affiliation(s)
- Fausta Beneventi
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Carla Badulli
- Immunogenetics Laboratory, Immunohematology and Transfusion Center, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Elena Locatelli
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy.
| | - Roberto Caporali
- Division of Rheumatology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Véronique Ramoni
- Division of Rheumatology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Chiara Cavagnoli
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Margherita Simonetta
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Giulia Garbin
- Immunogenetics Laboratory, Immunohematology and Transfusion Center, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Carmine Tinelli
- Clinical Epidemiology and Biometric Unit, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Claudia Alpini
- Clinical Chemistry Laboratory, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - CarloMaurizio Montecucco
- Division of Rheumatology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Miryam Martinetti
- Immunogenetics Laboratory, Immunohematology and Transfusion Center, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Arsenio Spinillo
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
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