1
|
Al-Riyami N, Salman B, Al-Rashdi A, Al-Dughaishi T, Al-Haddabi R, Hassan B. Pregnancy Outcomes in Systemic Lupus Erythematosus Women: A single tertiary centre experience. Sultan Qaboos Univ Med J 2021; 21:e244-e252. [PMID: 34221472 PMCID: PMC8219320 DOI: 10.18295/squmj.2021.21.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/08/2020] [Accepted: 08/13/2020] [Indexed: 11/19/2022] Open
Abstract
Objectives This study was conducted to assess pregnancy outcomes in women with systemic lupus erythematosus (SLE) in Oman. Methods A retrospective cohort study of 149 pregnancies in 98 women with SLE was conducted over 10 years to evaluate the impact of clinical and laboratory parameters in predicting adverse pregnancy outcomes. Results Mean maternal age was 30.6 ± 5 years ranging from 20–44 years, and the mean disease duration was 10 ± 5 years, ranging from 2–27 years. The most common maternal manifestations were joint pain in 36 (24.2%), lupus nephritis (LN) in 18 (12.08%), preeclampsia in 11 (7.4%), eclampsia in three (2%) and lupus flare in one pregnancy. The live birth rate was 139 (93.3%) with a mean gestational age of 36 ± 2 weeks ranging from 26–40 weeks. In total, 55 (39.6%) were preterm deliveries, six (4%) pregnancies ended in miscarriage, and four (2.7%) resulted in intrauterine fetal death. Intrauterine growth restriction was observed in 49 babies (35%). A significant association was found between hypertension (HTN) and miscarriage (P = 0.024) and preterm birth (P = 0.019). In addition, HTN was positively associated with preeclampsia (P = 0.004) and LN (P = 0.048). Antiphospholipid syndrome impacted preterm birth (P = 0.013) and postpartem haemorrhage (PPH) (P = 0.027) and was found to be a significant predictor for women developing deep vein thrombosis and pulmonary embolism (P <0.001 for both). Conclusion Despite potential complications, most pregnancies complicated by SLE in Oman result in good outcomes. Adverse pregnancy outcomes, however, may still occur in women with SLE. In women with SLE, pregnancy planning, careful antenatal monitoring and efficient SLE treatment need to be undertaken for successful pregnancy outcomes.
Collapse
Affiliation(s)
- Nihal Al-Riyami
- Department of Obstetrics & Gynecology, Sultan Qaboos University, Muscat, Oman
| | - Bushra Salman
- Pharmacy Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Amani Al-Rashdi
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Tamima Al-Dughaishi
- Department of Obstetrics & Gynecology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Rahma Al-Haddabi
- Department of Obstetrics & Gynecology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Batool Hassan
- Department of Medicine, Sultan Qaboos University, Muscat, Oman
| |
Collapse
|
2
|
Cecchi I, Radin M, Rodríguez-Carrio J, Tambralli A, Knight JS, Sciascia S. Utilizing type I interferon expression in the identification of antiphospholipid syndrome subsets. Expert Rev Clin Immunol 2021; 17:395-406. [PMID: 33686921 PMCID: PMC10183148 DOI: 10.1080/1744666x.2021.1901581] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Antiphospholipid Syndrome (APS) is a systemic autoimmune disease with a complex multifactorial pathogenesis, combining genetic background, traditional cardiovascular risk factors, disease-specific features such as the presence of antiphospholipid antibodies (aPL), and an imbalance of various immune system functions. Recent data support the role of interferons (IFNs), especially type IIFN (IFN-I), in the onset and development of APS clinical manifestations, including thrombotic events and obstetric complications. AREAS COVERED In this review, the authors aimed to discuss the growing body of evidence on the relevance of IFN-I pathways in APS, both from a basic mechanistic perspective, focusing on its possible use in disease/patients stratification. The IFN-I signature has shown promising, although preliminary, results in segregating aPL-positive subjects by aPL profile, association with other autoimmune conditions, such as lupus, age at onset, and current treatment, among others. EXPERT OPINION To date, the scarce available data as well as methodological and technical heterogeneity among studies limit the comparability of the results, thus requiring further validation to translate these findings to routine clinical practice. Therefore, further research is required in pursuit of more nuanced patient profiling and the development of new immunomodulatory therapeutic strategies for APS beyond anti-coagulant and antiplatelet agents.
Collapse
Affiliation(s)
- Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases - Nephrology and Dialysis Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases - Nephrology and Dialysis Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin Italy
| | - Javier Rodríguez-Carrio
- Department of Functional Biology, Immunology Area, Faculty of Medicine, University of Oviedo, Oviedo, Spain.,Group of Basic and Translational Research in Inflammatory Diseases, Instituto De Investigación Sanitaria Del Principado De Asturias (ISPA), Oviedo, Spain
| | - Ajay Tambralli
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases - Nephrology and Dialysis Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin Italy
| |
Collapse
|
3
|
Abstract
Antiphospholipid syndrome (APS), which is characterized by the presence of antiphospholipid antibodies (aPL), is associated with increased risk of thrombosis and obstetric complications, including preterm delivery and recurrent pregnancy losses. APS shows diverse clinical manifestations and the risk of complications varies among clinical subtypes. Although these patients are usually treated with aspirin and anticoagulants, the optimal treatment in various clinical settings is unclear, as the risk of complications vary among clinical subtypes and the management strategy depends on whether the patient is pregnant or not. Also, there are unmet needs for the evidence-based, pregnancy-related treatment of asymptomatic women positive for aPL. This review focuses on the management of positive aPL or APS in pregnant and postpartum women, and in women attempting to become pregnant. For asymptomatic aPL positive women, no treatment, low dose aspirin (LDA) or LDA plus anticoagulants can be considered during antepartum and postpartum. In obstetric APS patients, preconceptional LDA is recommended. LDA plus low molecular weight heparin is administered after confirmation of pregnancy. Vascular APS patients should take frequent pregnancy test and receive heparin instead of warfarin after confirmation of pregnancy. During pregnancy, heparin plus LDA is recommended. Warfarin can be restarted 4 to 6 hours after vaginal delivery and 6 to 12 hours after cesarean delivery. Most importantly, a tailored approach and patient-oriented treatment are mandatory.
Collapse
Affiliation(s)
- Eunyoung Emily Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.
| |
Collapse
|
4
|
Sciascia S, Radin M, Cecchi I, Rubini E, Scotta A, Rolla R, Montaruli B, Pergolini P, Mengozzi G, Muccini E, Baldovino S, Ferro M, Vaccarino A, Mahler M, Menegatti E, Roccatello D. Reliability of Lupus Anticoagulant and Anti-phosphatidylserine/prothrombin Autoantibodies in Antiphospholipid Syndrome: A Multicenter Study. Front Immunol 2019; 10:376. [PMID: 30891041 PMCID: PMC6411647 DOI: 10.3389/fimmu.2019.00376] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/14/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Is it well-known that one of the major drawbacks of Lupus Anticoagulant (LA) test is their sensitivity to anticoagulant therapy, due to the coagulation based principle. In this study we aimed to assess the reproducibility of LA testing and to evaluate the performance of solid assay phosphatidylserine/prothrombin (aPS/PT) antibodies. Methods: We included 60 patients that fulfilled the following inclusion criteria: (I) diagnosis of thrombotic antiphospholipid syndrome (APS); (II) patients with thrombosis and (a) inconstant previous LA positivity and/or (b) positivity for antiphospholipid antibodies (aPL) at low-medium titers [defined as levels of anti-β2Glycoprotein-I or anticardiolipin (IgG/IgM) 10–30 GPL/MPL] with no previous evidence of LA positivity. aPL testing was performed blindly in 4 centers undertaking periodic external quality assessment. Results: The 60 patients enrolled were distributed as follows: 43 (71.7%) with thrombotic APS, 7 (11.7%) with thrombosis and inconstant LA positivity and 10 (16.7%) with low-medium aPL titers. Categorical agreement for LA among the centers ranged from 0.41 to 0.60 (Cohen's kappa coefficient; moderate agreement). The correlation determined at the 4 sites for aPS/PT was strong, both quantitatively (Spearman rho 0.84) and when dichotomized (Cohen's kappa coefficients = 0.81 to 1.0). Discordant (as defined by lack of agreement in ≥3 laboratories) or inconclusive LA results were observed in 27/60 (45%) cases; when limiting the analysis to those receiving vitamin K antagonist (VKA), the level of discordant LA results was as high as 75%(15/20). Conversely, aPS/PT testing showed an overall agreement of 83% (up to 90% in patients receiving VKA), providing an overall increase in test reproducibility of +28% when compared to LA, becoming even more evident (+65%) when analyzing patients on VKA. In patients treated with VKA, we observed a good correlation for aPS/PT IgG testing (Cohen's kappa coefficients = 0.81–1; Spearman rho 0.86). Conclusion: Despite the progress in the standardization of aPL testing, we observed up to 45% of overall discrepant results for LA, even higher in patients on VKA. The introduction of aPS/PT testing might represent a further diagnostic tool, especially when LA testing is not available or the results are uncertain.
Collapse
Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy.,Nephrology and Dialysis Unit, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Anna Scotta
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy.,AOU Clinical Chemistry Laboratory, "Maggiore della Carità" University Hospital, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Roberta Rolla
- AOU Clinical Chemistry Laboratory, "Maggiore della Carità" University Hospital, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | | | - Patrizia Pergolini
- AOU Clinical Chemistry Laboratory, "Maggiore della Carità" University Hospital, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Giulio Mengozzi
- Department of Clinical Biochemistry, AOU Cittá della Salute e della Scienza, Turin, Italy
| | - Emanuela Muccini
- Department of Clinical Biochemistry, AOU Cittá della Salute e della Scienza, Turin, Italy
| | - Simone Baldovino
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Unit, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | | | - Michael Mahler
- Inova Diagnostics, Research and Development, San Diego, CA, United States
| | - Elisa Menegatti
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy.,Nephrology and Dialysis Unit, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| |
Collapse
|
5
|
Groot N, de Graeff N, Avcin T, Bader-Meunier B, Dolezalova P, Feldman B, Kenet G, Koné-Paut I, Lahdenne P, Marks SD, McCann L, Pilkington CA, Ravelli A, van Royen-Kerkhof A, Uziel Y, Vastert SJ, Wulffraat NM, Ozen S, Brogan P, Kamphuis S, Beresford MW. European evidence-based recommendations for diagnosis and treatment of paediatric antiphospholipid syndrome: the SHARE initiative. Ann Rheum Dis 2017; 76:1637-1641. [PMID: 28473426 DOI: 10.1136/annrheumdis-2016-211001] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [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: 12/20/2016] [Revised: 03/13/2017] [Accepted: 03/25/2017] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome (APS) is rare in children, and evidence-based guidelines are sparse. Consequently, management is mostly based on observational studies and physician's experience, and treatment regimens differ widely. The Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) initiative was launched to develop diagnostic and management regimens for children and young adults with rheumatic diseases. Here, we developed evidence-based recommendations for diagnosis and treatment of paediatric APS. Evidence-based recommendations were developed using the European League Against Rheumatism standard operating procedure. Following a detailed systematic review of the literature, a committee of paediatric rheumatologists and representation of paediatric haematology with expertise in paediatric APS developed recommendations. The literature review yielded 1473 articles, of which 15 were valid and relevant. In total, four recommendations for diagnosis and eight for treatment of paediatric APS (including paediatric Catastrophic Antiphospholipid Syndrome) were accepted. Additionally, two recommendations for children born to mothers with APS were accepted. It was agreed that new classification criteria for paediatric APS are necessary, and APS in association with childhood-onset systemic lupus erythematosus should be identified by performing antiphospholipid antibody screening. Treatment recommendations included prevention of thrombotic events, and treatment recommendations for venous and/or arterial thrombotic events. Notably, due to the paucity of studies on paediatric APS, level of evidence and strength of the recommendations is relatively low. The SHARE initiative provides international, evidence-based recommendations for diagnosis and treatment for paediatric APS, facilitating improvement and uniformity of care.
Collapse
Affiliation(s)
- Noortje Groot
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands.,Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Nienke de Graeff
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands
| | - Tadej Avcin
- University Children's Hospital, University Medical Centre, Ljubljana, Slovenia
| | | | - Pavla Dolezalova
- General University Hospital, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Brian Feldman
- The Hospital for Sick Children, University of Toronto, Canada
| | - Gili Kenet
- The Israel National Hemophilia Centre, Sackler Medical School, Sheba Medical Centre, Tel-Hashomer, Tel Aviv, Israel
| | | | - Pekka Lahdenne
- Hospital for Children and Adolescents, University of Helsinki, Finland
| | - Stephen D Marks
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Liza McCann
- Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | | | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genova, Italy
| | | | - Yosef Uziel
- Meir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Sebastiaan J Vastert
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands
| | - Nico M Wulffraat
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands
| | - Seza Ozen
- Department of Pediatrics, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Paul Brogan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sylvia Kamphuis
- Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Michael W Beresford
- Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| |
Collapse
|
6
|
Müller-Calleja N, Manukyan D, Canisius A, Strand D, Lackner KJ. Hydroxychloroquine inhibits proinflammatory signalling pathways by targeting endosomal NADPH oxidase. Ann Rheum Dis 2016; 76:891-897. [PMID: 27903507 DOI: 10.1136/annrheumdis-2016-210012] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [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: 06/03/2016] [Revised: 09/28/2016] [Accepted: 11/05/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Hydroxychloroquine (HCQ) has been used for decades to treat patients with rheumatic diseases, for example, systemic lupus erythematosus (SLE), rheumatoid arthritis or the antiphospholipid syndrome (APS). We hypothesise that HCQ might target endosomal NADPH oxidase (NOX), which is involved in the signal transduction of cytokines as well as antiphospholipid antibodies (aPL). METHODS For in vitro experiments, monocytic cells were stimulated with tumour necrosis factor α (TNFα), interleukin-1β (IL-1β) or a human monoclonal aPL and the activity of NOX was determined by flow cytometry. The expression of genes known to be induced by these stimuli was quantified by quantitative reverse transcription PCR. Live cell imaging was performed by confocal laser scanning microscopy. Finally, the effects of HCQ on NOX-induced signal transduction were analysed in an in vivo model of venous thrombosis. RESULTS HCQ strongly reduces or completely prevents the induction of endosomal NOX by TNFα, IL-1β and aPL in human monocytes and MonoMac1 cells. As a consequence, induction of downstream genes by these stimuli is reduced or abrogated. This effect of HCQ is not mediated by direct interference with the agonists but by inhibiting the translocation of the catalytic subunit of NOX2 (gp91phox) into the endosome. In vivo, HCQ protects mice from aPL-induced and NOX2-mediated thrombus formation. CONCLUSIONS We describe here a novel mechanism of action of HCQ, that is, interference with the assembly of endosomal NOX2. Since endosomal NOX2 is involved in many inflammatory and prothrombotic signalling pathways, this activity of HCQ might explain many of its beneficial effects in rheumatic diseases including the APS.
Collapse
Affiliation(s)
- Nadine Müller-Calleja
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Davit Manukyan
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Antje Canisius
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany
| | - Dennis Strand
- Department of Medicine 1, University Medical Center Mainz, Mainz, Germany
| | - Karl J Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany
| |
Collapse
|
7
|
Andreoli L, Bertsias GK, Agmon-Levin N, Brown S, Cervera R, Costedoat-Chalumeau N, Doria A, Fischer-Betz R, Forger F, Moraes-Fontes MF, Khamashta M, King J, Lojacono A, Marchiori F, Meroni PL, Mosca M, Motta M, Ostensen M, Pamfil C, Raio L, Schneider M, Svenungsson E, Tektonidou M, Yavuz S, Boumpas D, Tincani A. EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis 2016; 76:476-485. [PMID: 27457513 PMCID: PMC5446003 DOI: 10.1136/annrheumdis-2016-209770] [Citation(s) in RCA: 434] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/13/2016] [Accepted: 06/25/2016] [Indexed: 12/26/2022]
Abstract
Objectives Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). Methods Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus. Results Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease. Conclusions Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.
Collapse
Affiliation(s)
- L Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| | - G K Bertsias
- Department of Rheumatology, Clinical Immunology and Allergy, University of Crete Medical School, Heraklion, Greece
| | - N Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,The Faculty of Medicine, Tel Aviv University, Israel
| | - S Brown
- Royal National Hospital For Rheumatic Diseases, Bath, UK
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
| | - N Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - A Doria
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - R Fischer-Betz
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - F Forger
- Department of Rheumatology, Immunology and Allergology, University Hospital of Bern, Bern, Switzerland
| | - M F Moraes-Fontes
- Unidade de Doenças Auto-imunes-Serviço Medicina Interna 7.2, Hospital Curry Cabral/Centro Hospitalar Lisboa Central, NEDAI/SPMI, Lisboa, Portugal
| | - M Khamashta
- Lupus Research Unit, The Rayne Institute, St. Thomas Hospital, London, UK.,Department of Rheumatology, Dubai Hospital, Dubai, United Arab Emirates
| | - J King
- EULAR PARE Patient Research Partner, London, UK
| | - A Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Obstetrics and Gynaecology, Spedali Civili, Brescia, Italy
| | - F Marchiori
- EULAR PARE Patient Research Partner, Rome, Italy
| | - P L Meroni
- Department of Clinical Sciences and Community Health, University of Milan, Istituto Auxologico Italiano, Milan, Italy
| | - M Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Motta
- Neonatology and Neonatal Intensive Care Unit, Spedali Civili, Brescia, Italy
| | - M Ostensen
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - C Pamfil
- Department of Rheumatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - L Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Switzerland
| | - M Schneider
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - E Svenungsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Tektonidou
- Rheumatology Unit, Joint Academic Rheumatology Programme, 1st Department of Propaedeutic Internal Medicine Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - S Yavuz
- Department of Rheumatology, Istanbul Bilim University, Istanbul Florence Nightingale Hospital, Esentepe-Istanbul, Turkey
| | - D Boumpas
- 4th Department of Internal Medicine, 'Attikon' University Hospital, Medical School, University of Athens, Athens, Greece.,Joint Academic Rheumatology Program, National and Kapodestrian University of Athens, Athens, Greece
| | - A Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| |
Collapse
|
8
|
Domingues V, Magder LS, Petri M. Assessment of the independent associations of IgG, IgM and IgA isotypes of anticardiolipin with thrombosis in SLE. Lupus Sci Med 2016; 3:e000107. [PMID: 27403332 PMCID: PMC4932305 DOI: 10.1136/lupus-2015-000107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 04/21/2016] [Accepted: 04/30/2016] [Indexed: 11/06/2022]
Abstract
Objective The Sydney classification criteria for antiphospholipid syndrome include lupus anticoagulant or moderate-to-high titre anticardiolipin IgG or IgM. We explored the association of all anticardiolipin isotypes, lupus anticoagulant and the combination with venous and arterial thrombosis. Methods Patients with systemic lupus erythematosus (SLE) in a large clinical cohort seen quarterly were repeatedly tested by protocol for anticardiolipin antibodies and lupus anticoagulant. Subgroups of patients were defined based on the geometric mean titres of IgG, IgM, IgA anticardiolipin and lupus anticoagulant expressed in dilute Russell's viper venom time (RVVT) seconds for each patient across all cohort visits. These subgroups were compared with respect rates of thrombosis since diagnosis with SLE. Rate ratios were estimated using Cox Proportional Hazards models. Results Of the 1390 cohort members included, there were 284 thrombotic events observed over 17 025 person-years since diagnosis for a rate of 1.7 events per 100 person-years. Those with a geometric mean titre of IgG anticardiolipin >20 had a significantly elevated rate of thromboses (rate ratio 1.8, p=0.0052), whereas there was no evidence of an association between thromboses and elevated IgM geometric mean (rate ratio 1.2, p=0.40). There were relatively few cohort members with elevated IgA geometric mean but the rate of thromboses in that group was elevated (rate ratio 1.7, p=0.23). The associations between anticardiolipin antibodies and thromboses were strongest when considering venous thromboses. Those with two or more elevated anticardiolipin isotypes or those with both IgG anticardiolipin and RVVT did not appear at higher risk than those with a single elevated marker. Conclusion This study supports previous observations that IgG anticardiolipin and lupus anticoagulant are associated with higher rates of thromboses. Our power to study IgA anticardiolipin was limited due to small number of patients with elevated IgA.
Collapse
Affiliation(s)
- Vinicius Domingues
- Department of Rheumatology , New York University School of Medicine , New York, New York , USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health , University of Maryland, School of Medicine , Baltimore, Maryland , USA
| | - Michelle Petri
- Division of Rheumatology , Johns Hopkins University School of Medicine , Baltimore, Maryland , USA
| |
Collapse
|
9
|
Yelnik CM, Laskin CA, Porter TF, Branch DW, Buyon JP, Guerra MM, Lockshin MD, Petri M, Merrill JT, Sammaritano LR, Kim MY, Salmon JE. Lupus anticoagulant is the main predictor of adverse pregnancy outcomes in aPL-positive patients: validation of PROMISSE study results. Lupus Sci Med 2016; 3:e000131. [PMID: 26835148 PMCID: PMC4716418 DOI: 10.1136/lupus-2015-000131] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 01/28/2023]
Abstract
Objective We previously reported that lupus anticoagulant (LAC) is the main predictor of poor pregnancy outcome in antiphospholipid antibody (aPL)-positive patients. We sought to confirm this finding in an independent group of patients who were subsequently recruited into the PROMISSE study. Methods The PROMISSE study is a multicentre, prospective, observational study of pregnancy outcomes in women with aPL and/or systemic lupus erythematosus (SLE) that enrolled patients from 2003 to 2015. All consecutive, aPL-positive patients from the PROMISSE study who completed their pregnancy between April 2011 and January 2015 (after the previous PROMISSE report) are included in the current report. Patients were followed monthly until delivery, and aPL was tested at first, second and third trimesters of pregnancy and at 12 weeks post partum. Adverse pregnancy outcomes (APOs) were defined as fetal death after 12 weeks of gestation, neonatal death, delivery prior to 36 weeks of gestation due to pre-eclampsia or placental insufficiency or small-for-gestational age (birth weight <5th percentile). Results Forty-four aPL-positive patients are included in this paper. Thirteen patients had APOs, which occurred in 80% of cases during the second trimester of pregnancy. LAC was present in 69% of patients with APOs compared with 27% of patients without APOs (p=0.01). No association was found between anticardiolipin antibodies (aCL) or anti-β2 glycoprotein I antibodies (aβ2GPI) IgG or IgM positivity and APOs. Definite antiphospholipid syndrome (history of thrombosis and/or pregnancy morbidity and aPL) was found in 92% of patients with any APOs compared with 45% of patients without APOs (p=0.004). Conversely, the frequency of SLE was not statistically different between those with and without APOs (30% vs 39%). Conclusions Our findings, in an independent group of aPL-positive patients from the PROMISSE study, confirm that LAC, but not aCL and aβ2GPI, is predictive of poor pregnancy outcomes after 12 weeks of pregnancy. Trial registration number NCT00198068.
Collapse
Affiliation(s)
- Cecile M Yelnik
- Department of Medicine, Hospital for Special Surgery, New York City, New York, USA; Internal Medicine Department, University of Lille, UFR Médecine, Lille, France
| | - Carl A Laskin
- University of Toronto and LifeQuest Centre for Reproductive Medicine , Toronto , Canada
| | - T Flint Porter
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare , Salt Lake City, Utah , USA
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare , Salt Lake City, Utah , USA
| | - Jill P Buyon
- Department of Medicine, New York University School of Medicine , New York City, New York , USA
| | - Marta M Guerra
- Department of Medicine , Hospital for Special Surgery , New York City, New York , USA
| | - Michael D Lockshin
- Department of Medicine , Hospital for Special Surgery , New York City, New York , USA
| | - Michelle Petri
- Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland , USA
| | - Joan T Merrill
- Department of Medicine, Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA
| | - Lisa R Sammaritano
- Department of Medicine , Hospital for Special Surgery , New York City, New York , USA
| | - Mimi Y Kim
- Department of Epidemiology and Public Health, Albert Einstein College of Medicine , New York City, New York , USA
| | - Jane E Salmon
- Department of Medicine , Hospital for Special Surgery , New York City, New York , USA
| |
Collapse
|
10
|
Mankee A, Petri M, Magder LS. Lupus anticoagulant, disease activity and low complement in the first trimester are predictive of pregnancy loss. Lupus Sci Med 2015; 2:e000095. [PMID: 26688740 PMCID: PMC4680586 DOI: 10.1136/lupus-2015-000095] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/05/2015] [Indexed: 11/12/2022]
Abstract
Introduction Multiple factors, including proteinuria, antiphospholipid syndrome, thrombocytopenia and hypertension, are predictive of pregnancy loss in systemic lupus erythematosus (SLE). In the PROMISSE study of predictors of pregnancy loss, only a battery of lupus anticoagulant tests was predictive of a composite of adverse pregnancy outcomes. We examined the predictive value of one baseline lupus anticoagulant test (dilute Russell viper venom time) with pregnancy loss in women with SLE. Methods From the Hopkins Lupus Cohort, there were 202 pregnancies from 175 different women after excluding twin pregnancies and pregnancies for which we did not have a first trimester assessment of lupus anticoagulant. We determined the percentage of women who had a pregnancy loss in groups defined by potential risk factors. The lupus anticoagulant was determined by dilute Russell viper venom time with appropriate mixing and confirmatory testing. Generalised estimating equations were used to calculate p values, accounting for repeated pregnancies in the same woman. Results The age at pregnancy was <20 years (2%), 20–29 (53%), 30–39 (41%) and >40 (3%). 55% were Caucasian and 34% African-American. Among those with lupus anticoagulant during the first trimester, 6/16 (38%) experienced a pregnancy loss compared with only 16/186 (9%) of other pregnancies (p=0.003). In addition, those with low complement or higher disease activity had a higher rate of pregnancy loss than those without (p=0.049 and 0.005, respectively). In contrast, there was no association between elevated anticardiolipin in the first trimester and pregnancy loss. Conclusions The strongest predictor of pregnancy loss in SLE in the first trimester is the lupus anticoagulant. In addition, moderate disease activity by the physician global assessment and low complement measured in the first trimester were predictive of pregnancy loss. These data suggest that treatment of the lupus anticoagulant could be considered, even in the absence of history of pregnancy loss.
Collapse
Affiliation(s)
- Anil Mankee
- Division of Rheumatology , Icahn School of Medicine at Mount Sinai , New York, New York , USA
| | - Michelle Petri
- Division of Rheumatology and Immunology , Johns Hopkins University School of Medicine , Baltimore, Maryland , USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health , University of Maryland , Baltimore, Maryland , USA
| |
Collapse
|
11
|
Abstract
Systemic lupus erythematosus (SLE) is one of the most challenging autoimmune disorders with a complex pathophysiology and diverse clinical presentation. Many drugs have been used to treat SLE with suboptimal results, especially in patients with moderate-to-severe disease. Belimumab is the first biological drug to be approved for the treatment of SLE in more than 50 years. This monoclonal antibody blocks B-cell activating factor, a cytokine important for B-cell differentiation and survival. In this review we focus on the activity of belimumab in patients with SLE and discuss the controversies of its use.
Collapse
Affiliation(s)
- Andreia Vilas-Boas
- Internal Medicine Department , Hospital Pedro Hispano , Matosinhos , Portugal
| | - Sandra A Morais
- Internal Medicine Department , Hospital Pedro Hispano , Matosinhos , Portugal
| | - David A Isenberg
- Centre for Rheumatology, University College London Hospitals , London , UK
| |
Collapse
|
12
|
Cousins L, Pericleous C, Khamashta M, Bertolaccini ML, Ioannou Y, Giles I, Rahman A. Antibodies to domain I of β-2-glycoprotein I and IgA antiphospholipid antibodies in patients with 'seronegative' antiphospholipid syndrome. Ann Rheum Dis 2014; 74:317-9. [PMID: 25359383 PMCID: PMC4283613 DOI: 10.1136/annrheumdis-2014-206483] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Laura Cousins
- Centre for Rheumatology Research, University College London, London, UK
| | - Charis Pericleous
- Centre for Rheumatology Research, University College London, London, UK
| | - Munther Khamashta
- Lupus Research Unit, The Rayne Institute, King's College London School of Medicine, London UK
| | | | - Yiannis Ioannou
- Centre for Rheumatology Research, University College London, London, UK Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, UK
| | - Ian Giles
- Centre for Rheumatology Research, University College London, London, UK
| | - Anisur Rahman
- Centre for Rheumatology Research, University College London, London, UK
| |
Collapse
|
13
|
Marder W, Romero VC, Ganser MA, Hyzy MA, Gordon C, McCune WJ, Somers EC. Increased usage of special educational services by children born to mothers with systemic lupus erythematosus and antiphospholipid antibodies. Lupus Sci Med 2014; 1:e000034. [PMID: 25379194 PMCID: PMC4213825 DOI: 10.1136/lupus-2014-000034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/20/2014] [Accepted: 06/22/2014] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Surveys of long-term health and developmental outcomes of children born to mothers with systemic lupus erythematosus (SLE) have suggested an increase in learning disabilities among these children. We performed this observational study to investigate the relationship between maternal autoantibodies and antiphospholipid antibody syndrome (APS) in maternal lupus patients and neurocognitive development among their offspring. METHODS SLE mothers with at least one live birth postlupus diagnosis were enrolled. Data on maternal medical/obstetric history and children's perinatal/medical history were collected by structured interview and medical record reviews. The primary outcome was requirement for special educational (SE) services, a proxy for developmental delays. Multiple logistic regression modelling was used to examine associations between APS and autoantibodies with SE usage, accounting for SLE disease severity and potential confounders. RESULTS Data on 38 mothers and 60 offspring were analysed: SE service usage was reported for 15 of 60 (25%) offspring. Maternal APS history was significantly associated with increased use of SE services among offspring, including after adjustment for lupus anticoagulant (LA) positivity and potential confounders (OR 5.5-9.4 for delays age ≥2; p<0.05). The presence of LA, but not other antiphospholipid antibodies, was also associated with increased SE services usage. CONCLUSIONS Maternal APS and LA were independently associated with increased usage of special educational services among offspring of women with SLE.
Collapse
Affiliation(s)
- Wendy Marder
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vivian C Romero
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Martha A Ganser
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Margaret A Hyzy
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Caroline Gordon
- School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - W J McCune
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily C Somers
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
14
|
Sciascia S, Sanna G, Khamashta MA, Cuadrado MJ, Erkan D, Andreoli L, Bertolaccini ML. The estimated frequency of antiphospholipid antibodies in young adults with cerebrovascular events: a systematic review. Ann Rheum Dis 2014; 74:2028-33. [PMID: 24942381 DOI: 10.1136/annrheumdis-2014-205663] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [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: 04/01/2014] [Accepted: 06/01/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Around 10% of all thrombotic cerebrovascular events (CVE) occur in young population and in a large proportion of those the trigger remains undetermined. Antiphospholipid antibodies (aPL) are recognised risk factors for ischaemic stroke and recurrent thrombotic events; however, the frequency of aPL in young people with CVE is still an unresolved issue. OBJECTIVES To estimate the frequency of aPL in young adults with CVE and to determine whether aPL-positive young individuals are at greater risk of CVE when compared with individuals without aPL by systematically reviewing the literature. METHODS Medline reports published between 1970 and 2013 investigating the presence of aPL in young patients (<50 years old) with CVE were included. The median frequency for positive aPL, including lupus anticoagulant, anticardiolipin antibodies (aCL) and antibodies against β2Glycoprotein I (anti-β2GPI), was calculated for stroke and transient ischaemic attacks. FINDINGS This systematic review is based on available data from 5217 patients and controls from 43 studies analysing the frequency of aPL in young patients with CVE. The overall aPL frequency was estimated as 17.4% (range 5%-56%) for any CVE, 17.2% (range 2%-56%) for stroke and 11.7% (range 2%-45%) for transient ischaemic attack (TIA). The presence of aPL increased the risk for CVE by 5.48-fold (95% CI 4.42 to 6.79). Based on available data, the frequency of aPL in young patients with CVE can be estimated at 17%, rising up to 22% for aCL in patients with stroke. The presence of aPL seems to confer a fivefold higher risk for stroke or TIA when compared with controls. However, variability in test reproducibility and cut-off definition still represent an important methodological limitation for the current diagnostic testing for aPL. These observations should be confirmed by appropriately designed population studies.
Collapse
Affiliation(s)
- Savino Sciascia
- Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, London, UK Centro di Ricerche di Immunologia Clinica ed Immunopatologia e Documentazione su Malattie Rare (CMID), Università di Torino, Torino, Italy
| | - Giovanni Sanna
- Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Munther A Khamashta
- Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, London, UK Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Maria Jose Cuadrado
- Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, and Weill Medical College of Cornell University, New York
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Laura Bertolaccini
- Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, London, UK
| | | |
Collapse
|
15
|
Gustafsson JT, Gunnarsson I, Källberg H, Pettersson S, Zickert A, Vikerfors A, Möller S, Rönnelid J, Elvin K, Svenungsson E. Cigarette smoking, antiphospholipid antibodies and vascular events in Systemic Lupus Erythematosus. Ann Rheum Dis 2014; 74:1537-43. [PMID: 24692586 DOI: 10.1136/annrheumdis-2013-205159] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 03/16/2014] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Smoking can induce autoantibodies in persons who are genetically predisposed to rheumatoid arthritis. We investigated the association between smoking and antiphospholipid antibodies (aPL) in systemic lupus erythematosus (SLE), a question not previously addressed. Further, we explored the relationship between smoking, aPL and vascular events (arterial and venous, VE). METHODS In this cross-sectional study, clinical evaluation and questionnaire data were collected from 367 prevalent SLE patients. At the same time, we measured aPL (anticardiolipin (aCL), anti-β2 glycoprotein-1 (aβ2GP1) antibodies IgG/IgM/IgA, and lupus anticoagulant (LA)), and a large set of other SLE-associated autoantibodies for comparison. Association analyses using logistic regression models with smoking, (ever, former and current with never as reference) and antibody status as outcome variable were performed. As a secondary outcome, we investigated the associations between aPL, smoking and VE. RESULTS In multivariable-adjusted models ever, and in particular former, cigarette smoking was associated with the most pathogenic aPL; LA, aCL IgG and aβ2GP1 IgG. Other SLE-associated autoantibodies were not associated with smoking. The combination of smoking and aPL was strongly associated with VE. We noted a positive interaction between smoking-LA and smoking-'triple aPL' positivity for previous VE. CONCLUSIONS We investigated a large set of commonly occurring autoantibodies in SLE, but only aPL were positively associated with a history of smoking. This association was especially apparent in former smokers. Among ever regular smokers who were aPL positive, we observed a strikingly high frequency of former VE. The underlying mechanisms and temporality between smoking, aPL and VE need further investigations.
Collapse
Affiliation(s)
- Johanna T Gustafsson
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Iva Gunnarsson
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Källberg
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Pettersson
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Zickert
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Anna Vikerfors
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Sonia Möller
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Rönnelid
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory C5, Uppsala University, Uppsala, Sweden
| | - Kerstin Elvin
- Unit of Clinical Immunology, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Elisabet Svenungsson
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
16
|
Erkan D, Willis R, Murthy VL, Basra G, Vega J, Ruiz-Limón P, Carrera AL, Papalardo E, Martínez-Martínez LA, González EB, Pierangeli SS. A prospective open-label pilot study of fluvastatin on proinflammatory and prothrombotic biomarkers in antiphospholipid antibody positive patients. Ann Rheum Dis 2013; 73:1176-80. [PMID: 23933625 DOI: 10.1136/annrheumdis-2013-203622] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine if proinflammatory and prothrombotic biomarkers are differentially upregulated in persistently antiphospholipid antibody (aPL)-positive patients, and to examine the effects of fluvastatin on these biomarkers. METHODS Four groups of patients (age 18-65) were recruited: (a) primary antiphospholipid syndrome; (b) systemic lupus erythematosus (SLE) with antiphospholipid syndrome (APS) (SLE/APS); (c) persistent aPL positivity without SLE or APS (Primary aPL); and (d) persistent aPL positivity with SLE but no APS (SLE/aPL). The frequency-matched control group, used for baseline data comparison, was identified from a databank of healthy persons. Patients received fluvastatin 40 mg daily for 3 months. At 3 months, patients stopped the study medication and they were followed for another 3 months. Blood samples for 12 proinflammatory and prothrombotic biomarkers were collected monthly for 6 months. RESULTS Based on the comparison of the baseline samples of 41 aPL-positive patients with 30 healthy controls, 9/12 (75%) biomarkers (interleukin (IL)-6, IL1β, vascular endothelial growth factor (VEGF), tumour necrosis factor (TNF)-α, interferon (IFN)-α, inducible protein-10 (IP10), soluble CD40 ligand (sCD40L), soluble tissue factor (sTF) and intracellular cellular adhesion molecule (ICAM)-1) were significantly elevated. Twenty-four patients completed the study; fluvastatin significantly and reversibly reduced the levels of 6/12 (50%) biomarkers (IL1β, VEGF, TNFα, IP10, sCD40L and sTF). CONCLUSIONS Our prospective mechanistic study demonstrates that proinflammatory and prothrombotic biomarkers, which are differentially upregulated in persistently aPL-positive patients, can be reversibly reduced by fluvastatin. Thus, statin-induced modulation of the aPL effects on target cells can be a valuable future approach in the management of aPL-positive patients.
Collapse
Affiliation(s)
- Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Medical College of Cornell University, , New York, NY, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Lundström E, Gustafsson JT, Jönsen A, Leonard D, Zickert A, Elvin K, Sturfelt G, Nordmark G, Bengtsson AA, Sundin U, Källberg H, Sandling JK, Syvänen AC, Klareskog L, Gunnarsson I, Rönnblom L, Padyukov L, Svenungsson E. HLA-DRB1*04/*13 alleles are associated with vascular disease and antiphospholipid antibodies in systemic lupus erythematosus. Ann Rheum Dis 2012; 72:1018-25. [PMID: 22893315 DOI: 10.1136/annrheumdis-2012-201760] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Vascular disease is common in systemic lupus erythematosus (SLE) and patients with antiphospholipid antibodies (aPL) are at high risk to develop arterial and venous thrombosis. Since HLA class II genotypes have been linked to the presence of pro-thrombotic aPL, we investigated the relationship between HLA-DRB1 alleles, aPL and vascular events in SLE patients. METHODS 665 SLE patients of Caucasian origin and 1403 controls were included. Previous manifestations of ischaemic heart disease, ischaemic cerebrovascular disease (ICVD) and venous thromboembolism (together referred to as any vascular events (AVE)) were tabulated. aPL were measured with ELISA. Two-digit HLA-DRB1 typing was performed by sequence-specific primer-PCR. RESULTS HLA-DRB1*04 was more frequent among SLE patients with ICVD compared to unaffected patients. This association remained after adjustment for known traditional cardiovascular risk factors. HLA-DRB1*13 was associated with AVE. All measured specificities of aPL-cardiolipin IgG and IgM, β2-glycoprotein-1 IgG, prothrombin (PT) IgG and a positive lupus anticoagulant test were associated with HLA-DRB1*04-while HLA-DRB1*13 was associated with IgG antibodies (β2-glycoprotein-1, cardiolipin and PT). In patients with the combined risk alleles, HLA-DRB1*04/*13, there was a significant additive interaction for the outcomes AVE and ICVD. CONCLUSIONS The HLA-DRB1*04 and HLA-DRB1*13 alleles are associated with vascular events and an aPL positive immune-phenotype in SLE. Results demonstrate that a subset of SLE patients is genetically disposed to vascular vulnerability.
Collapse
Affiliation(s)
- Emeli Lundström
- Department of Medicine, Rheumatology Unit, Karolinska Institutet/Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|