Management of Thrombotic Antiphospholipid Syndrome

Persistent serum positivity for antiphospholipid antibodies (aPL) is required to diagnose antiphospholipid syndrome (APS), an autoimmune disease characterized by recurrent vascular thrombosis and/or pregnancy morbidity. The current therapeutic management of patients with thrombotic APS aims at preventing recurrences and long-term complications by attenuating the procoagulant state. There is overall consensus to reserve moderate-intensity anticoagulation to aPL-positive patients with a previous venous thrombosis; the therapeutic options for those with a history of arterial event comprise antiplatelet agents and high-intensity anticoagulation. Unfortunately, thrombotic occurrences might occur despite adequate anticoagulation, carrying a significant burden of morbidity and mortality. The management of refractory thrombotic APS and catastrophic APS is still not clear, warranting the issue of recommendations. Vitamin-K antagonists are limited by significant side effects, and a careful weighting of risks and benefits should be performed to reserve the optimal treatment to each patient. To overcome these limitations, novel oral anticoagulants have been introduced in the market, but their efficacy in thrombotic APS has still to be unraveled. The poor safety profile and the scarce efficacy of drugs acting on the coagulation cascade explain why novel therapeutic approaches are currently under investigation, to identify pharmacological tools specifically counteracting aPL-mediated prothrombotic effects

Treatment of Thrombotic Antiphospholipid Syndrome : The Rationale of Current Management - An Insight into Future Approaches

Vascular thrombosis and pregnancy morbidity represent the clinical manifestations of antiphospholipid syndrome (APS), which is serologically characterized by the persistent positivity of antiphospholipid antibodies (aPL). Antiplatelet and anticoagulant agents currently provide the mainstay of APS treatment. However, the debate is still open: controversies involve the intensity and the duration of anticoagulation and the treatment of stroke and refractory cases. Unfortunately, the literature cannot provide definite answers to these controversial issues as it is flawed by many limitations, mainly due to the recruitment of patients not fulfilling laboratory and clinical criteria for APS. The recommended therapeutic management of different aPL-related clinical manifestations is hereby presented, with a critical appraisal of the evidence supporting such approaches. Cutting edge therapeutic strategies are also discussed, presenting the pioneer reports about the efficacy of novel pharmacological agents in APS. Thanks to a better understanding of aPL pathogenic mechanisms, new therapeutic targets will soon be explored. Much work is still to be done to unravel the most controversial issues about APS management: future studies are warranted to define the optimal management according to aPL risk profile and to assess the impact of a strict control of cardiovascular risk factors on disease control

Transforming growth factor beta1 in the pathogenesis of autoimmune congenital complete heart block : lesson from twins and triplets discordant for the disease

Objective. Clinical evidence and experimental evidence suggest that anli-Ro/La autoantibodies are necessary but not sufficient for the development of congenital complete heart block (CCHB). Maternal, fetal, and environmental factors may also contribute to heart damage in CCHB. The aim of our study was to investigate polymorphisms of transforming growth factor \u3b21 (TGF\u3b21) and tumor necrosis factor \u3b1 (TNF\u3b1) genes in twins and triplets discordant for CCHB whose mothers are anti-Ro/La positive. Methods. We studied 2 families in which 1 of the mothers gave birth to triplets and the other gave birth to twins. Only 1 child in each family was affected by CCHB, although 1 of the triplets had incomplete heart block. We analyzed TNF\u3b1 and TGF\u3b21 polymorphisms in the 2 babies with CCHB and their siblings. TNF\u3b1 polymorphisms at the promoter region and TGF\u3b21 polymorphisms at codons 10 and 25 were determined using polymerase chain reaction-restriction fragment length polymorphism analysis. In addition, the production of TGF\u3b21 and TNF\u3b1 by resting or mitogen-stimulated peripheral blood mononuclear cells in cell culture supernatants was evaluated by enzyme-linked immunosorbent assay. Results. The profibrotic TGF\u3b21 genotype was detected in the twin with CCHB but not in the healthy twin, while all of the triplets displayed the same TGF\u3b21 genotype at codon 10. Peripheral blood mononuclear cells from the children with CCHB displayed higher spontaneous and mitogen-stimulated T6F\u3b21 secretion than was observed in their siblings. No differences regarding TNF\u3b1 polymorphisms and secretion of TNF\u3b1 were observed. Conclusion. The results of this study suggest that, besides anti-Ro/La autoantibodies, a fetal profibrotic response might contribute to the development of CCHB, but additional pathogenic mechanism(s) are also likely to play a role

Subpopulations of anti-β2glycoprotein I antibodies with different pathogenic potential: fine specificity against the domains of β2glycoprotein I

Objective: Anti-β2glycoprotein I antibodies (a-β2GPI) are a laboratory criterion for the antiphospholipid syndrome (APS) and were demonstrated to be involved in the pathogenesis of APS. However, they can also be detected in asymptomatic subjects. It has been suggested that a-β2GPI against Domain1 (D1) associate with thrombosis, while those recognizing Domain4/5 (D4/5) have been identified in non-thrombotic conditions. We evaluate the specificity of a- β2GPI in different clinical situations. Methods: We studied 39 one-year-old healthy children born to mothers with systemic autoimmune diseases (SAD) (15 (38.4%) were born to mothers who were a-β2GPI positive), 33 children with atopic dermatitis (AD) and 55 patients with APS (50 adults and 5 paediatrics). All subjects were IgG a-β2GPI positive. IgG a-β2GPI were performed by homemade ELISA, while IgG a-β2GPI D1 and D4/5 were tested on research ELISAs containing recombinant β2GPI domains antigens. Results: One-year-old children and AD children displayed preferential reactivity for D4/5; patients with APS recognized preferentially D1. We also found a good correlation between a-β2GPI and D4/5 in one-year-old (r=0.853) and AD children (r=0.879) and between a-β2GPI and D1 in the APS group (r=0.575). No thrombotic events were recorded in both groups of children. Conclusions: A-β2GPI found in non-thrombotic conditions (healthy children born to mothers with SAD and AD children) mostly recognize D4/5, in contrast to the prevalent specificity for D1 in the APS group. The different specificity could at least partially explain the "innocent" profile of a-β2GPI in children

Immune complexes containing scleroderma-specific autoantibodies induce a profibrotic and proinflammatory phenotype in skin fibroblasts

Background: In systemic sclerosis (SSc), autoantibodies provide the most accurate tool to predict the disease subset and pattern of organ involvement. Scleroderma autoantibodies target nucleic acids or DNA/RNA-binding proteins, thus SSc immune complexes (ICs) can embed nucleic acids. Our working hypothesis envisaged that ICs containing scleroderma-specific autoantibodies might elicit proinflammatory and profibrotic effects in skin fibroblasts. Methods: Fibroblasts were isolated from skin biopsies obtained from healthy subjects and patients with diffuse cutaneous SSc (dcSSc). ICs were purified by polyethylene-glycol precipitation from sera of SSc patients bearing different autoantibodies. ICs from patients with systemic lupus erythematosus (SLE) and primary anti-phospholipid syndrome (PAPS) and from normal healthy subjects (NHS) were used as controls. After incubation with ICs, fibroblasts were evaluated for ICAM-1 expression, interleukin (IL)-6, IL-8, monocyte chemoattractant protein (MCP)-1, matrix metalloproteinase (MMP)-2, tumor growth factor (TGF)-\u3b21 and Pro-CollagenI\u3b11 secretion, collagen (col)I\u3b11, mmp-1, toll-like receptor (tlr)2, tlr3, tlr4, tlr7, tlr8, tlr9, interferon (ifn)-\u3b1, ifn-\u3b2 and endothelin-1 mRNA, and NF\u39aB, p38MAPK and SAPK-JNK activation rate. Experiments were also performed after pretreatment with DNase I/RNase and NF\u39aB/p38MAPK inhibitors. Results: The antigenic reactivity for each SSc-IC mirrored the corresponding serum autoantibody specificity, while no positivity was observed in NHS-ICs or sera. SSc-ICs but not NHS-ICs increased ICAM-1 expression, stimulated IL-6, IL-8, MMP-2, MCP-1, TGF-\u3b21 and Pro-CollagenI\u3b11 secretion, upregulated et-1, ifn-\u3b1, ifn-\u3b2, tlr2, tlr3 and tlr4, and activated NF\u39aB, p38MAPK and SAPK-JNK. tlr9 was significantly upregulated by ARA-ICs, mmp-1 was significantly induced by ACA-ICs whereas colI\u3b11 was not modulated by any SSc-ICs. SLE-ICs and PAPS-ICs significantly upregulated MMP-2 and activated NF\u39aB, p38MAPK and SAPK-JNK. SLE-ICs and PAPS-ICs did not affect colI\u3b11, mmp-1 and Pro-CollagenI\u3b11. DNase I and RNase treatment significantly reduced the upregulation of study mediators induced by SSc-ICs. Pretreatment with NF\u39aB/p38MAPK inhibitors suggested that response to anti-Th/To-ICs was preferentially mediated by p38MAPK whereas ATA-ICs, ACA-ICs and ARA-ICs engaged both mediators. In dcSSc fibroblasts, stimulation with SSc-ICs and NHS-ICs upregulated IL-6 and IL-8. Conclusions: These data provide the first demonstration of the proinflammatory and profibrotic effects of SSc-ICs on fibroblasts, suggesting the potential pathogenicity of SSc autoantibodies. These effects might be mediated by Toll-like receptors via the interaction with nucleic acid fragments embedded in SSc-ICs

Drug survival and reasons for discontinuation of the first course of biological therapy in 301 juvenile idiopathic arthritis patients

The objective of this study was to determine long-term effectiveness and safety of 1st biological treatment (BT) in a cohort of 301 juvenile idiopathic arthritis (JIA) patients (pts), non-responders to disease-modifying antirheumatic drugs (DMARDs), in terms of drug survival (continuation rate on therapy) and to identify the baseline predictors of treatment discontinuation. Each JIA pt enrolled in BT is prospectively assessed at the start of treatment and then every 2 months for the evaluation of safety and efficacy according to ACR-Pedi30 criteria. All clinical charts of pts who started a BT between November 1999 and July 2010 have been reviewed. Survival analysis methods suitable for competing risks were used to study time to drug discontinuation due to disease control (defined according to Wallace criteria) or failure [adverse event (AE), lack of efficacy (LaE) or loss of efficacy (LoE) according ACR-Pedi30]. A number of 301 JIA pts, non-responders or intolerant to DMARDs and treated with one or more cycles of BT, were identified. Median disease duration, from onset to the beginning of 1st BT, was 7.8 years (interquartil range 2.21-15.1). In total, there were 294 1st corses with anti-TNF agents, 5 with abatacept and 2 with anakinra. A number of 298 pts were included in the analysis for drug discontinuation (3 pts with no follow-up data after their first dose of BT were excluded). The median follow-up on treatment, before discontinuation due to every cause, was 53.7 months (range 0.45-124.45). One hundred and sixty-five pts discontinued BT: 27 due to disease control, 135 because of failure (78 AEs, 12 LaE and 45 LoE), 3 pts temporarily stopped for pregnancy. Among 135 pts who discontinued for failure, 117 switched to a 2nd BT. Among 27 pts who discontinued due to remission, 13 pts restarted on BT for relapse of disease activity (10 pts restarted with the same BT, 3 switched to a different one). Predictors of discontinuation due to AE were female gender (P=0.01) and longer disease duration (P=0.02). Predictors of discontinuation due to LaE or LoE were systemic onset and polyarthritis FR positive (vs other JIA subtypes) (P<0.05) and use of mAb-anti-TNF (vs sTNFR) (P=0.02). Predictors of discontinuation due to inactive disease were male gender and shorter disease duration (P<0.05). Although only few pts discontinued BT due to a complete and persistent disease control, the majority of them remained on BT for a long time, suggesting that in our cohort of JIA pts, affected by a severe long lasting refractory disease, BT was globally well tolerate and efficacious in controlling the disease

Anti-beta 2 glycoprotein I antibodies in centenarians

Non-organ-specific autoantibodies are present in centenarians without evidence of autoimmune diseases but conflicting or no data on anti-phospholipid and anti-phospholipid binding proteins were reported. To investigate the presence and antigen specificity of anti-phospholipid and anti-phospholipid binding proteins in centenarians. Seventy-seven centenarians, 70 adult controls, 65 unselected elderly subjects, and 38 old SENIEUR volunteers were investigated. Anti-cardiolipin, anti-human \u3b22glycoprotein I, and lupus anticoagulant were detected. Antigen specificity was assayed against plates coated with anionic, neutral and cationic phospholipids and \u3b22glycoprotein I-dependence was also evaluated. 54.3% of the centenarians were positive for IgG and 8.6% for IgM anti-\u3b22glycoprotein I antibodies, while only 20.7% centenarians were positive for anti-cardiolipin IgG and 2.59% for IgM; none resulted positive for lupus anticoagulant. Anti-cardiolipin positive sera cross-reacted with negatively charged phospholipids and displayed decreased binding to serum-free cardiolipin-coated plates that was restored by human \u3b22glycoprotein I or fetal calf serum. Centenarians display high reactivity against human \u3b22glycoprotein I but low binding to the bovine molecule in the anti-cardiolipin assay. In spite of the presence of antibodies comparable to those found in patients with the anti-phospholipid syndrome, no vascular events were reported suggesting the presence of unknown protective factors and/or the lack of triggering factors

The Risk of Obstetric Complications and the Effects of Treatment in Women with Low Titer and Medium-High Titer Anti-Phospholipid Antibodies

Background/Purpose: The association of low titer anti-phospholipid antibodies (aPL) with obstetric anti-phospholipid syndrome (APS) is increasingly acknowledged, even though some studies have showed conflicting results. To raise further evidence on the relevance of low titer aPL in pregnancy morbidity (PM), we retrospectively reviewed the clinical records of pregnant women attending a joint obstetric/rheumatology clinic over the years 2009-2016. Methods: Patients were included when positive in at least one criteria aPL assay, at any titer, in two occasions minimum 12 weeks apart. Statistical analysis was performed using R package. Results: 111 women (338 pregnancies) were identified. 51 women displayed low-titer aPL, with 160 pregnancies. 60 patients carried aPL at medium-high titers, with 178 pregnancies. 4 patients (4%) had thrombotic APS, 27 (24%) obstetric APS, 7 (6%) thrombotic and obstetric APS, 15 (14%) medium-high titer aPL and non criteria PM, 7 (6%) medium-high titer aPL and no PM, 18 (16%) low titer aPL and non criteria PM and 15 (14%) low titer aPL and no PM. Low-titer aPL were significantly associated with pregnancy complications (c2=8.82, p=0.003). Considering 245 untreated pregnancies, a significant difference in PM distribution was noted for low titer and medium-high titer aPL (p=0.003, Table 1). Among patients with low titer aPL, treatment with low molecular weight heparin [LMWH] + low-dose aspirin [LDASA] significantly improved pregnancy outcomes (p<<0.001, odds ratio [OR]=0.07, 95% CI=0.007\u20130.300), leading to a 14.3-fold reduction of obstetric complications. Hydroxychloroquine [HCQ] was not associated with a significant improvement in live birth rate (p=0.079). Among women with medium-high titer aPL, the standard therapeutic approach with LMWH+LDASA resulted in a significant improvement of obstetric outcome (p<<0.001, OR=0.20, 95% CI=0.100\u20130.400). HCQ treatment significantly improved obstetric outcome, carrying a 3-fold increase in the live birth rate (p=0.025, OR=0.34, 95% CI=0.117\u20130.894). Conclusion: According to our data, low titer aPL are significantly associated with aPL-associated obstetric complications, with a lower prevalence of premature birth compared to medium-high titer aPL. Treatment with LDASA+LMWH led to a higher increase of live birth rate in women with low titer aPL compared to those with medium-high titer aPL. Additional treatment such as HCQ were effective in women with medium-high titer aPL but not those with low titer aPL. Table 1. Obstetric outcomes (defined according to Miyakis et al, 2006) in 245 untreated pregnancies in women with low titer and medium-high titer anti-phospholipid antibodies