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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Bala MM, Celinska-Lowenhoff M, Szot W, Padjas A, Kaczmarczyk M, Swierz MJ, Undas A. Antiplatelet and Anticoagulant Agents for Secondary Prevention of Thromboembolic Events in People With Antiphospholipid Syndrome. Stroke 2018. [DOI: 10.1161/strokeaha.117.019900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Malgorzata M. Bala
- From the Department of Hygiene and Dietetics (M.M.B., W.S.), Systematic Reviews Unit - Polish Cochrane Branch (M.M.B., M.K., M.J.S.), 2nd Department of Internal Medicine, Department of Allergy and Immunology (M.C.-L.), and Institute of Cardiology (A.U.), Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Celinska-Lowenhoff
- From the Department of Hygiene and Dietetics (M.M.B., W.S.), Systematic Reviews Unit - Polish Cochrane Branch (M.M.B., M.K., M.J.S.), 2nd Department of Internal Medicine, Department of Allergy and Immunology (M.C.-L.), and Institute of Cardiology (A.U.), Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Szot
- From the Department of Hygiene and Dietetics (M.M.B., W.S.), Systematic Reviews Unit - Polish Cochrane Branch (M.M.B., M.K., M.J.S.), 2nd Department of Internal Medicine, Department of Allergy and Immunology (M.C.-L.), and Institute of Cardiology (A.U.), Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Padjas
- From the Department of Hygiene and Dietetics (M.M.B., W.S.), Systematic Reviews Unit - Polish Cochrane Branch (M.M.B., M.K., M.J.S.), 2nd Department of Internal Medicine, Department of Allergy and Immunology (M.C.-L.), and Institute of Cardiology (A.U.), Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Kaczmarczyk
- From the Department of Hygiene and Dietetics (M.M.B., W.S.), Systematic Reviews Unit - Polish Cochrane Branch (M.M.B., M.K., M.J.S.), 2nd Department of Internal Medicine, Department of Allergy and Immunology (M.C.-L.), and Institute of Cardiology (A.U.), Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz J. Swierz
- From the Department of Hygiene and Dietetics (M.M.B., W.S.), Systematic Reviews Unit - Polish Cochrane Branch (M.M.B., M.K., M.J.S.), 2nd Department of Internal Medicine, Department of Allergy and Immunology (M.C.-L.), and Institute of Cardiology (A.U.), Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- From the Department of Hygiene and Dietetics (M.M.B., W.S.), Systematic Reviews Unit - Polish Cochrane Branch (M.M.B., M.K., M.J.S.), 2nd Department of Internal Medicine, Department of Allergy and Immunology (M.C.-L.), and Institute of Cardiology (A.U.), Jagiellonian University Medical College, Krakow, Poland
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Celinska-Lowenhoff M, Iwaniec T, Alhenc-Gelas M, Musial J, Undas A. Arterial and venous thrombosis and prothrombotic fibrin clot phenotype in a Polish family with type 1 antithrombin deficiency (antithrombin Krakow). Thromb Haemost 2017; 106:379-81. [DOI: 10.1160/th11-02-0066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 05/15/2011] [Indexed: 11/05/2022]
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Bala MM, Celinska-Lowenhoff M, Padjas A, Szot W, Undas A. Antiplatelet and anticoagulant agents for secondary prevention of stroke and other thromboembolic events in people with antiphospholipid syndrome. Cochrane Database Syst Rev 2016. [DOI: 10.1002/14651858.cd012169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Jakiela B, Iwaniec T, Plutecka H, Celinska-Lowenhoff M, Dziedzina S, Musial J. Signs of impaired immunoregulation and enhanced effector T-cell responses in the primary antiphospholipid syndrome. Lupus 2015; 25:389-98. [PMID: 26657472 DOI: 10.1177/0961203315618267] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/26/2015] [Indexed: 12/31/2022]
Abstract
INTRODUCTION We investigated whether primary antiphospholipid syndrome (PAPS) is characterized by a deficiency in immunoregulatory pathways, a phenomenon recently implicated in the pathogenesis of autoimmune diseases. METHODS Serum levels of immunoregulatory (e.g., IL-10 and TGF-β1) and proinflammatory (e.g., IL-17A) cytokines were measured in PAPS, systemic lupus erythematosus (SLE) with secondary APS (SAPS), or without APS, and in healthy controls (n = 40 in each group). In a subgroup of PAPS patients we also compared phenotype and function (flow cytometry) of regulatory T-cells (Treg) and cytokine production by effector T-cells. RESULTS Our major finding was decreased levels of TGF-β1 in PAPS and SAPS as compared to SLE without APS and controls. TGF-β1 was the lowest in PAPS patients showing high levels of aPL IgG with significant negative correlation with the titer. SLE patients were characterized by lower serum levels of IL-2 and increased IL-17A, as compared to the other groups. The numbers of circulating Treg cells and their phenotype (e.g., FoxP3 isoforms) were not disturbed in PAPS. However, surface expression of latency associated peptide (binds TGF-β) in activated FoxP3 + cells and in vitro production of TGF-β1 were decreased in PAPS patients with high titers of aPL IgG. Moreover, frequencies of cytokine producing effector T-helper cells (including Th17) were significantly elevated in this group. CONCLUSIONS PAPS patients with high titers of aPL IgG antibodies were characterized by decreased systemic levels of TGF-β1 and its impaired production in vitro, suggesting impaired immunoregulation and enhanced adaptive autoimmune responses leading to the production of aPL antibodies.
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Affiliation(s)
- B Jakiela
- Jagiellonian University Medical College, Department of Medicine, Krakow, Poland
| | - T Iwaniec
- Jagiellonian University Medical College, Department of Medicine, Krakow, Poland
| | - H Plutecka
- Jagiellonian University Medical College, Department of Medicine, Krakow, Poland
| | | | - S Dziedzina
- Jagiellonian University Medical College, Department of Medicine, Krakow, Poland
| | - J Musial
- Jagiellonian University Medical College, Department of Medicine, Krakow, Poland
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Son M, Wypasek E, Celinska-Lowenhoff M, Undas A. The use of rivaroxaban in patients with antiphospholipid syndrome: A series of 12 cases. Thromb Res 2015; 135:1035-6. [PMID: 25669601 DOI: 10.1016/j.thromres.2015.01.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 01/26/2015] [Accepted: 01/29/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Maksim Son
- Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Ewa Wypasek
- Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland; John Paul II Hospital, Cracow, Poland
| | | | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland; John Paul II Hospital, Cracow, Poland.
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Plazak W, Padjas A, Celinska-Lowenhoff M, Iwaniec G, Swadzba J, Luberda T, Musial J, Podolec P. Antiphospholipid antibodies and coronary atherosclerosis: the antiphospholipid syndrome patients. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht310.p5503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Potaczek DP, Undas A, Celinska-Lowenhoff M, Szczeklik A. The I Allele of the Angiotensin-Converting Enzyme Gene Polymorphism may Determine an Increase in Homocysteine Levels in Fibrate-Treated Subjects. Cardiovasc Drugs Ther 2006; 20:229-32. [PMID: 16779534 DOI: 10.1007/s10557-006-8374-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The aim of the study was to investigate the influence of the angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism on nonlipid effects of statins and fibrates in hypercholesterolemic subjects. C-reactive protein, homocysteine, adhesion molecules, CD40 ligand, interleukin-6 and monocyte chemoattractant protein-1 were measured prior to and following 30 days of simvastatin or fenofibrate therapy. Decreases in all the variables except for adhesion molecules and homocysteine were observed in both treatment groups, without genotype-related differences. Interestingly, fenofibrate treatment led to a significant increase in homocysteine levels (p = 0.03) only in carriers of the I allele. In conclusion, ACE genotype might help identify patients prone to this effect of fibrates.
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Affiliation(s)
- Daniel P Potaczek
- Department of Medicine, Jagellonian University School of Medicine, 8 Skawinska Str., 31-066 Cracow, Poland
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Domagala T, Celinska-Lowenhoff M, Dropinski J, Gozdecka H, Gnass M, Borkowska-Mosur A, Szezeklik A. Th-P16:302 Fenofibrate increases homocysteine and N-methylnicotinamide levels through PPARalpha-mediated mechanism. ATHEROSCLEROSIS SUPP 2006. [DOI: 10.1016/s1567-5688(06)82260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Potaczek DP, Undas A, Celinska-Lowenhoff M, Szczeklik A. Interleukin-6 −174 G/C promoter polymorphism and effects of fenofibrate and simvastatin on inflammatory markers in hypercholesterolemic patients. Blood Coagul Fibrinolysis 2006; 17:35-8. [PMID: 16607077 DOI: 10.1097/01.mbc.0000198052.65505.00] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To evaluate whether the interleukin-6 (IL-6) -174 G/C polymorphism might alter the effects of micronized fenofibrate or simvastatin therapy on inflammatory markers, we measured IL-6, C-reactive protein, CD40 ligand, adhesion molecules, P-selectin and monocyte chemoattractant protein-1 in hypercholesterolemic patients both before and after a 30-day treatment. Serum IL-6 levels were significantly higher in patients with the GC or CC genotypes (P=0.04). The presence of the C allele was associated with greater absolute reduction of IL-6 levels (P=0.04) following fenofibrate treatment. There was no significant association between the -174 G/C IL-6 polymorphism and the effects of simvastatin treatment. A relationship between the -174 G/C IL-6 polymorphism and the anti-inflammatory action of fenofibrate reported might be useful in the optimization of the treatment regimen in patients receiving this class of drugs.
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Affiliation(s)
- Daniel P Potaczek
- Department of Medicine, Jagellonian University School of Medicine, Cracow, Poland
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Celinska-Lowenhoff M, Undas A, Domagala T, Iwaniec T, Szczeklik A. 2P-0617 Pleiotropic effects after a 3-day treatment with the lipid lowering drugs in patients with coronary artery disease. ATHEROSCLEROSIS SUPP 2003. [DOI: 10.1016/s1567-5688(03)90756-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Domagala T, Undas A, Celinska-Lowenhoff M, Rybak M, Szczeklik A. 2P-0385 Methionine loading affects thrombin generation in patients with coronary artery disease. ATHEROSCLEROSIS SUPP 2003. [DOI: 10.1016/s1567-5688(03)90528-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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