A discovery is said to be an accident meeting a prepared mind. A discovery is said to be an accident meeting a prepared mind. A discovery is said to be an accident meeting a prepared mind
Case description in brief. A young female was admitted in casualty with swelling of rt lower limb. On examination pulses absent. USG showed thrombus. h/o revealed –marriage life 0f 18 months---2 months later had an ischemic stroke---after 7 months became pregnant---6 months miscarriage,severe pl. insufficiency---after 2 months she had swelling of rt lower limb—DVT---on 1stjune had abd pain—hemorrhagic cyst of ovary—stopped acitrom---DVT. INR---3.3 at discharge Diagnosis suspected of APLS APL ab positive---Ig G ACL—90GPL,IgM ,IgA were positive. Patient was kept on warfarin----to be followed up.
INTRODUCTION Also known as HUGHES SYNDROME. LUPUS ANTI COAGULANT SYNDROME (misnomer) Autoimmune disorder.----acquired thrombophilic disorder. Mostly assosciated with SLE. Responsible for frequent miscarriages in young females (15%). CATASTROPHIC APS---Asherson’s syndrome. MC thrombotic defect leading to fetal wastage.
Graham R.V. Hughes
DEFINITION A patient with definite APS must have persistent high titer antiphospholipid antibodies(APL) assosciated with a history of arterial or venous thrombosis or both ,or recurrent pregnancy morbidity.—(clinical criteria) and laboratory criteria. CAPS Asymptomatic antiphospholipid antibodies Probable antiphospholipid syndrome Seronegativeantiphospholipid syndrome(SNAP) Microangiopathicantiphospholipid syndrome Drug induced Infection assosciated Malignancy assosciated.
CLINICAL CRITERIA—( SAPPORO CRITERIA) APS is present if at least one of the clinical criteria and one of the laboratory criteria that follow are met…. Clinical criteria--- 1.vascular thrombosis One or more clinical episodes of arterial,venousor small vessel thrombosis,occuring in any tissue or organ.to be confirmed by objective validated criteria.histopathologically thrombosis should be present without significant evidence of inflammation in the vessel wall. 2.pregnancy morbidity a.one or more unexplained deaths of morphologically normal fetuses at or after the 10 week of gestation. b.one or more premature births of morphologically normal neonates before the 34th week of gestation—ecclampsia,sev pl insufficiency c.three or more unexplained consequtive sp abortions before the 10th week of gestation—anatomic,hormonalabn excluded.
Laboratory criteria 1.lupus anticoagulant present in plasma. 2.aCL of IgG and or IgMisotypein serum or plasma,present in medium or high titer(>40GPL,40MPL,>99TH percentile) 3.anti β2GP1IgG or IgMisotypein serum or plasma On two or more occasions at least 12 weeks apart. Diagnostic clues for individual patients but not as classification criteria for the purpose of clinical trials Cardiac valve disease,livedoreticularis,thrombocytopenia,renal thrombotic microangiopathy,neurological manifestations-chorea Non criteria antibodies—IgAaCL,IgAantiΒ2gp1,antiphosphatidylserine ab,antiphosphatidyl ethanolamine ab,ab against prothrombinalone,ab to Ph.serine-PT complex.
Advances in criteria 1999---sapporoconcensus conference 2004---sydney conference revised Numerous modifications were made to the initial statement. Better defining of clinical criteria by confirmation. Stratification of patients with APS presence or absence of other inherited or acquired contributing cause of thrombosis. APS with or without assosciated rheumatic disease. CAPS Asymptomatic aPL Time interval increased to 12 weeks Transient positivity to be excluded Add of b2gp1 ab Diagnostic clues J thrombhaemost 2006:4:295-306 Arthritis Rheum 1999;42:1309-11 JAPI,mar 2010—176-183
EPIDEMIOLOGY In young,app healthy people---for LA,antiCL is 1-5% Prevalence ↑ with age ,in elderly with chronic disease. Risk of thrombosis is 0.5-30% Women :men is 5:1 Mean age of onset-31 yrs Low age 8 months Females---arthritis,livedo,migraine Males—MI,epilepsy,lower extremity arterial thrombosis ACA ass with thrombosis>LA ---5:1 Acl in elderly More common in africanamericans. Without rheumatic disease at younger age and with rh –older Apl ab—30-40% in SLE---10% have APLS Idiopathically—ACL-24%,LA-4%
The clinical manifestation of thrombosis is similar whether the APL is primary or secondary. Removed in 2006. Common auto immune diseases ass with APL ab are 1.SLE-25-50% 2.sjogren’s –42% 3.RA-33% 4.AITP-30% 5.AIHA-unknown 6.PA-28% 7.SS-25% 8.MCD-22% 9.behcet-20% 10.PMR-20%
etiology Unknown cause Possible triggers identified and stratified accordingly. Most of the autoimmune disorders ass with APLab WHETHER IT ITSELF INVOLVED IN PATHOGENESIS OR IS AN EPIPHENOMENON IS ? Relatives of persons with known APS—33% freq have APLab HLA –DRW53,DR7—HISPANIC,DR4 white.
PATHOGENESIS Homeostatic regulation of blood coagulation is altered. 1.defect in cellular apoptosis---exposure of membrane phospholipids to the binding of various plasma proteins---b2gp1---complex—epitope---target for autoantibodies. 2.oxidized b2GP1---activates dendritic cells –autoantibodies are produced. 3.production of antibodies against prothrombin,proteinC,Sannexins. 4.activation of platelets to enhance endothelial adherence. 5.activation of vascular endothelium—platelet and monocyte binding. 6.ab against oxidized LDL—atherosclerosis.
Complement activation has been increasingly recognised as a possible significant role in the pathogenesis of APS. Blood. Jan 15 2007;109(2):422-30. Nat Med. Nov 2004;10(11):1222-6. The family of APL ab are heterogenous and the targets vary. APS can be caused by –LA,ACA,B2GP1 or other antibodies. There are distinct clinical ,laboratory and biochemical differences between the disorders mediated by the different antibodies. ACL---risk of stroke—arterial thrombosis LA-venous TNF alpha –pregnancy loss
Mechanism of thrombosis Precise mechanism is unclear. Heterogenous---several mechanisms are responsible. ‘phospholipids are an integral part of platelet And endothelial cell surface membranes ,it is expected that these antibodies have a effect on them.’
How do they mediate???? Inhibition of endothelial cell prostacyclin production ClinApplThrombHemost 1999;5;s76 Procoagulant effect on platelets Br J Haematol 2002:119;781 Impairement of fibrinolysis Interference with the thrombomodulin-proteinS-proteinC pathway J Autoimmun 2007;28(2-3):129-33 Induction of procoagulant activity on endothelial cells and/or monocytesClin Exp Immuno 2000;120:537 Disruption of the annexinVcellular shield FertilSteril 2002l;77:805 Abnormal cytotrophoblast expression of adhesion molecules in pregnancy NEJM2002;346 (10);752-63
ACA– are directed against cardiolipin They may be b2 gp1 dependent or independent Independent—syphilis B2 gp1-----apolipoprotein H Bind with cardiolipinab --thrombosis
What do the animal models say??? Question the non inflammatory ,thrombotic state Evidence for complement activation is crucial for complications in pregnancy. Inflammation mediated tissue injury in pregnancy Therapy should be against inflammation Ann N Y AcadSci 2005 ;1051:413-20 Mouse model of APS---heparin prevents complement activation induced by APL. Use of specific complement inhibitors in APS—future TNF alpha– as a critical effector in pregnancy loss—TNF blockade
Risk factors for thrombosis Age >55 in men,>65 in women Risk factor for CVD* Inherited thrombophilias Oral contraceptives Nephrotic syndrome Malignancy Immobilization Surgery *htn,DM2,LDL,↓HDL,cigarette smoking,family h/o BMI>30kg/m2,microalbuminuria,GFR<60ml/min
CLINICAL FEATURES(SPECTRUM) 1.VENOUS THROMBOSIS Lower extremities 29-55% caes >50% have asymptomatic pulmonary embolism Seen at unsual sites Cerebral veins may be affected Superior sagittal sinus SeminThrombHemost 1999;25:333-50
Retinal vein thrombosis
2.ARTERIAL THROMBOSIS Less common Males Present with TIA or stroke 50%,MI(25%) Presence of anti CL ab—risk factor Involvement of large and small vessels—unique Brachial,subclavian arteries Peripheral arteries NEJM 2002;346;752-63 Dis Mon 2003;49:696-741 SeminThrombHemost 1999:25;333-50
Retinal artery thrombosis
3. CARDIAC disorders Thrombotic or embolic Premature athreosclerosis—occlusion Apl inv in young age with no risk factors for CaVD Valvular thickening—M.,A Vegetations ----libmann sacks Premature coronary disease Myocardial infarction Diffuse cardiomyopathy CHF Pericardial effusion Pulmonary hypertension In SLE---pericarditis is common,novalvularreg,withhtn –HF,onlyepicardial ischemia. J thrombthrombolysis 2005;20;105-12
4.NEUROLOGICAL disorders Thrombotic or embolic LA—venous,ACL—arterial---risk factor for stroke in young Recurrent strokes—multi infarct dementia No other risk factors are present “chorea is another clinical diosrder that has been strongly linked to presence of APL” Migraine,TM,GBS,ON,ICH,psychosis Mimics multiple sclerosis—cognitive dysfunction Diff—chorea,migraine,seizure ,dysarthria mc in apl,ON,bowel ,bladder ,gait—MS Non enhancing with gadolinium,stronglypoisitiveab---APLS Dis Mon 2003;49(12):696-741,Thromb Res 2004;114;489-99,Ann N Y AcadSci 2005
5.obstetrical disorders Recurrent miscarriages Fetal demise Ecclampsia IUGR Oligohydramnios HELLP syndrome May be the prsenting feature of APLS MC thrombotic defect leading to fetal demise---15% of miscarriages HaemtolOncolClin North Am 2008;22;33-52
6.DERMATOLOGICAL May be the presenting feature Noninflammatory vascular thrombosis Livedoreticularis is more common Cutaneuos ulcerations Subungual splinter hemorrhages Anetoderma Patients with livedoreticularis and APS frequently have cardiac and cerebral thrombotic events,epilepsy,migraine headaches Cerebral---SNEDDON’S syndrome Clin Exp Rheumatol 2005;23;499-504
Subungual splinter hemorrhage
7.PULMONARY Most frequent arterial complication Thromboembolism of lung arteries ARDS Diffuse alveolar hemorrhage—non thrombotic manifestation of APS High mortality 8.ABDOMINAL Hepatic involvement is common Acalculouscholecystitis Giant gastric ulceration 9.ENDOCRINE Adrenal insufficiency Thyroid 10.RETINAL---CRAO,CRVO,ON,CiRAO 11.HEMATOLOGY-----thrombocytopenia<1,00,000. Severe—CAPS,TTP <50,000—bleeding
12.RENAL APLN---renal manifestation of APLS Thrombosis at any site. Non thrombotic –glomerulonephritis 25% patients have renal ---mostly IgGab Nil/membranous nephropathy Patient—with flank pain,RVT,proteinuria---check for APL Urine analysis---mod proteinuria,hematuria Ischemic mesangiolysis,vessel hyperplasia <10%--ARF—recurrence Warfarin,steroids,plasmapheresis Lupus 2006,15;485-9
Catastrophic Antiphospholipid Syndrome(CAPS) A syndrome of multisystem involvement . <1% of patients. Multiple small vessel occlusions---multi organ failure. Acute onset 3 different organ systems Acute microangiopathy is characteristic ARF,ARDS,CEREBRAL INJURY,MYOCARDIAL ischemia. Potentially lethal Trigger factors involved---infections,trauma,neoplasia,pregnancy,lupus flares. ICU SLE-higher mortality.
PPts of CAPS
Catastrophic antiphospholipid syndrome
A note on other syndromes Asymptomatic---??? Apl---risk factor,requires other trigger for APLS—double hit theory. h/o thrombosis,LA,aclIgG---FIVE FOLD Probable– Lack the clinical criteria of vascular thrombosis or pregnancy loss. Livedo,chorea,thrombocytopenia. Livedoreticularis the first manifestation—41% Seronegative Clinical manifestations but no identifiable ab Repeat testing---positive. Microangiopathic Microvascular---TTP,HELLP,CAPS Drug induced Infection assosciated malignancy
DRUG induced Cardiac---procainamide,quinidine,propanolol,hydralazine. Neuroleptic or psychiatric—phenytoin,chlorpromazine. Other-interferon alpha,quinine,amoxicillin Infection— Syphilis HCV HIV HTLV type 1 Malaria Septicemia.
LAB DIAGNOSIS APA---IgG,IgA,IgM SEVERAL antibodies are recognised Recently—antibodies against annexinV,protein C IgMacl---HEMOLYTIC ANEMIA. IgG ACL –thrombosis False positive test result for syphilis ACL—membrane phospholipids LA-plasma coagulation molecules Elongates APTT,Kaolin clotting time,diluterussells viper venom time.
Kaolin clotting test
INR The ISI—1.0-2.0 INR—5 high chance of bleeding 0.5--- clot formation Normal range is 0.9-1.3 Warfarin ---2.0-3.0 Prosthetic valves—3.0-4.0
LUPUS ANTICOAGULANT LABORATORY artifact. Interferes with the action of phospholipid cofactors in the coagulation cascade in lab assays—prolongation of time to clot—mimics anticoagulant response. Misnomer—ass with thrombosis. Inhibits the formation of prothrombinase complex within the coagulation cascade. It blocks the binding of prothrombin and factor Xa to phospholipids---thrombin formation inhibited. It can be Ig G,A,M 10%of SLE Venous thrombosis
How you diagnose LA Normal Platelets-- poor plasma is mixed with patient’s plasma If a clotting factor is deficient,the addition of normal plasma corrects the prolonged clotting time. If the clotting time does not normalize ,an inhibitor is present. The absence of a specific clotting factor inhibitor confirms that LA is present.
What if LA,ACL are negative If patient experiencing thrombosis or recurrent miscarriages Order Antibodies to b2 gp1 Ab to phosphatidylserine,ethonalamine,glycerol,inositol Annexin V Phosphatidylcholine.
DRVVT Detection of LA In vitro test ---ability of venom of russells viper to induce thrombosis. Coagulant in venom directly activates factor X—turns prothrombin to thrombin in presence of factor V and phospholipid. In drvvt assay time is set to 23-27 sec A prolonged clotting time of 30 sec or greater that does not correct with addition of an equal volume of normal plasma suggests the presence of LA. Excess phospholipid is added. Normalised Both the tests are determined to a ratio. >1.2---may have.1.6 ---confirm. More sensitive than APTT for LA
Diluted Russells viper venom test
Imaging studies For confirmation USG COLOR DOPPLER CT SCAN MRI 2D ECHO Histology----non inflammatory bland thrombosis with no signs of perivascular inflammation or leukocytoclasticvasculitis.
DIFFERENTIAL DIAGNOSIS Think of any other thrombophilic states before making a diagnosis of APLS. Malignancy OCP Homocysteinemia Antithrombin 111 def Protein C,S def Factor V leiden mutation
TREATMENT Asymptomatic individuals in whom blood test findings are positive do not requires specific treatment. In pregnancy---use heparin and aspirin Previously prednisolone was used—no benefit as per trials Increases premnaturity,hypertension. No beneficial role of immunoglobulins in pregnancy. 1.with one fetal loss or mulitple abortions---aspirin plus heparin. Warfarin only after organogenesis is complete Nursing is safe
Prophylactic therapy— Eliminate other risk factors Low dose aspirin,clopidogrel SLE—hydroxychloroquine—intrinsic antithrombotic properties. Statins may be used—fluvastatin. Thrombosis--- IV /sc heparin---warfarin Reasonable INR is 2.0-3.0 for venous,3.0 for arterial,recurrent—3.0-4.0---think of bleeding if >5.0 Life long anticoagulation
Obstetric--- Prophylaxis for with no h/o thrombosis Full anticoagulation with h/o thrombosis. Sc heparin,low dose aspirin With held at the time of delivery. CAPS—steroids Recurrent DVT ---ivc filter. Patient education Avoid prolonged immobilization.
Current recommendations Primary thrombosis prevention---lack of evidence based approach. Arthritis Rheum 2004;50;s640-1 for sec prevention—life long warfarin. Duration,intensity ---still debate. In case of fetal loss h/o-low dose aspirin+LMWH-----fail-----Ivig effective only in reports. CurrRheumatol Report2002(4);379-86 CAPS—anticoagulation,steroids,IVIG,plasma exchange. Arthritis Rheumat 2003;48(12);3320-7 Elimination of reversible risk factors Prophylaxis during high risk periods are crucial
How much warfarin should be used? Both moderate INR 2-3 and high intensity anticoagulation (INR 3-4) are similar protective in APS patients after the first thrombosis---NEJM 2003;349;1133-8,J ThrombHaemost 2005;3:848-53 Excess of minor bleeding in high intensity group. target of INR 2.5 High target in case of recurrence. Intensity in case of arterial events is still deabte?????///
No data to support primary prevention of stroke in asymptomatic carriers of APL. Risk factors—use low dose aspirin. Anticoagulate patients with INR 3.0 Long term warfarin therapy. How long should we use warfarin???/ Lifelong Recurrence may not be higher in APL patients on discontinuation of warfarin—10% What is the effect of discontinuation—trials are going on..
Is warfarin complete treatment? Efficacy in microangiopathicnephropathy,valvular heart disease ,livedoreticularis, leg ulcers is not supported by data. In asymptomatic patients???????/// 178 persistently positive patients---thrombosis free were followed for three years witrhout anticoagulation---no patient developed thrombosis. J Rheuma 2004,31;1560-7
Alternatives to warfarin Dipyridamole,ticlopidine,clopidogrel---sec prevention of non cardio embolic strokes---only clopidogrel effective. Recurrence rate is 5-10% with these agents. Direct thrombin inhibitors role ??? But can be used in HIT CAPS---rituximab,an anti CD20 MONOCLONAL AB HYDROXYXHLOROQUINE Statins—fluvastatin decreases thrombus size.
Ximelagatran—first oral thrombin inhibitor. Neutralises clot bound thrombin. Melgatran—rapid onset of action,shorter half life. No interaction Superior to warfarin after TKRS. Cause LFT changes Not approved by FDA in 2004-----www.astrazeneca.com
doses Warfarin---5-15mg/day qd for 2-5 days INR 2.5-3.5 LMWH—low dose 20-40mg/day SC,1 mg/kg SC bid –high dose. Unfractionated—SC 5000-10,000u q12h IV—5,000 U ---1000-2000U/Hr Weight based 80U/Kg ---18U/Kg/h iv APTT 2 times baseline----factor Xa assays in case of LA. aspirin 81mg/day Hydroxychloroquine—6-7mg/kg/d---200-400mg/d Cyclophosphamide 2-3 mg/kg/d PO OD, Steroids—prednisolone 1 mg/kg bw IV ig---400mg/kg/d iv for 5 days Statins ---atorva 10mg,pravastatin 40m g,fluvastatin 5 mg
New drugs Rituximab 1000mg iv for 2 doses.seperated by 2 weeks. Rate at 50mg/h eculizumab
FOLLOW UP Frequent check ups Adequate patient education Avoidance of smoking Strict control with anticoagulants. In case of bleeding –hospital. Normal healthy life
TRIALS Eculizumab to Enable Renal Transplantation in Patients With History of Catastrophic Antiphospholipid Antibody Syndrome by john hopkinsuniversity,nov 2009. Genetic Risk Factors Associated With Antiphospholipid Antibody Syndrome---JUNE 2006---JULY 2009---Individuals with APL and family h/o APL compared with APL patients with h/o of only othr rheumatic disorders.—observational Pilot Study of Cyclophosphamide in Patients With Life-Threatening Systemic Lupus ErythematosusorAntiphospholipid Antibody Syndrome----
Reliability of Point-of-Care INR Measurements in Patients With Antiphospholipid-Antibody SyndromeTreated With Warfarin----comparing with venupuncture Predictors of Pregnancy Outcome in Systemic Lupus Erythematosus (SLE) and Antiphospholipid Syndrome (APS) (PROMISSE) Antiphospholipid Syndrome Collaborative Registry (APSCORE) effects of Fluvastatin on Proinflammatory and Prothrombotic Markers in AntiphospholipidSyndromePatients Hematopoietic Stem Cell Transplantation in Patients With Antiphospholipid Syndrome A Pilot Study of Rituximab for the Anticoagulation Resistant Manifestations of Antiphospholipid Syndrome(RITAPS)
Low-molecular-weight Heparin (LMWH) Versus Unfractionated Heparin (UFH) in Pregnant Women With History of Recurrent Abortion Secondary to Antiphospholipid Syndrome. Steroids and Antiphospholipid Syndrome- Related Pregnancy Loss Low Molecular Weight Heparin and Aspirin in the Treatment of Recurrent Pregnancy Loss: A RCT (HepASA) Pharmacokinetics of Low Molecular Weight and Unfractionated Heparin in Pregnancy LOG on to clinicaltrials.gov
future Target based treatment Specific complement inhibitors Using anticoagulation in times of need. Primary prevention drug Alternative effective drug to warfarin.
TAKE HOME MESSAGE Think of APLS in a young female with thrombosis,fetal wastage. Recurrent migraine headaches in a young female –do APL INR to be individualized and mainatined at 2.0-3.0 Recurrent –3.0-4.0 LA—DRVVT HEPARIN –FACTOR XA IgG ACL –THROMBOSIS Ig M ACL—HEMOLYTIC ANEMIA LIVEDO RETICULARIS –THINK OF APLS CHOREA IN YOUNG –THINK OF APLS ACL –INCREASES WITH AGE ACL—ARTERIAL,LA—VENOUS LIFE LONG ANTICOAGULATION CAPS—ICU CARE
SUMMARY An autoimmune disease ,acquired, assosciated with heterogenous antibodies which act through various mechanisms—leading to thrombosis---diagnosis by sapporo criteria—confirmation on thrombosis for diagnosis---seperation of lab tests by 12 weeks---warfarin life long therapy—heparin in pregnancy----CAPS– acute emergency---INR to be monitored----risk to be explained.---future trends of target therapy awaited.
discussion 1.what you do in a case of a female who is diagnosed as having APLS,was kept on warfarin –had previous miscarriage—now wants to conceive----? Ans—stop warfarin if the patient wants to conceive.and put her on heparin.again shift her to warfarin postpartum. You said after she diagnosed as pregnant
2.what you will do in 2 cases with status epilepticus---patient treated,both being young was advised—CT scan brain—one had infarct,othernormal,both APL being positive .with no h/o of previous thrombosis or APL postivity Ans—the APL positivity to be confirmed again after 12 weeks.if they are positive then attribute it to APLS.the false positivty of APL ab are high---the drugs used for the treatment of status epilepticus—phenytoin –may also cause an increase in APL ab.in both the test to be confirmed after 12 weeks.and treatment of thrombosis to be started at that time You said treatment for the one having thrombosis to be taken.
queries Your vocabulary is not appropriate,adequate. You were stopping in the middle. You could not explain the drvvt. You could not explain CAPS adequately.
Read about What is the one causing LA to lead to thrombosis or per se it causes thrombosis? Normally coagulation takes place on exposure of the endothelium—how is the endothelium exposed in case of APLS? What were the patients with pregnancy using in case of PROMISSE trial? Normally complement activation leads to hemolysis—how is it causing thrombosi? Annexin v ab to be explained? Pathogenesis to be explained? LA is a coagulant not an anticoagulant.
All were present during my presentation. Juniors were present Total duration was 42 min.—exhaustive. I lost the tempo. Date of presentation—23-06-2010.