Antiphospholipid Syndrome.

Antiphospholipid Syndrome 

Dr. John Hanly 

Division of Rheumatology, 

Arthritis Centre of Nova Scotia, 

Capital Health and Dalhousie University, 

Halifax, Nova Scotia, Canada

Disclosures 

• Peer-reviewed grants (current) 

CIHR, Capital Health 

• Unrestricted grants from industry 

Abbott, Roche, Schering, UCB 

• Clinical trials 

Abbott, UCB 

• Advisory boards 

UCB, Roche, GSK


Objectives 

• Definition antiphospholipid syndrome (APS) 

• Laboratory detection of aPL antibodies 

• Pathogenesis and clinical manifestations 

• Case presentations and treatment

Antiphospholipid Antibodies 

Measurement 

Binding assays 

(ELISA) 

Functional 

coagulation assays 

• Anticardiolipin 

• VDRL 

• Lupus anticoagulant 

(LAC ratio)

(Hanly JG CMAJ 2003;168(13):1675)

IgG Anticardiolipin Antibodies 

(((Hanly et al J Rheum 1996; 23:1543)

Phospholipid-binding 

Proteins 

• Initially called “cofactors” 

• Ubiquitous serum proteins 

• 2 -glycoprotein I 

Prothrombin 

Protein C 

Protein S 

Annexin V

(Hanly JG CMAJ 2003;168(13):1675)

Lupus Anticoagulant 

International Criteria 

• Prolongation of phospholipid-dependent 

coagulation assay (e.g. RVVT, PTT, KCT) 

• Failure to correct inhibition of in-vitro 

coagulation with normal plasma (“50:50 mix”) 

• Correction of inhibition of in-vitro coagulation 

with exogenous phospholipid 

(Brandt JT et al. Thromb Haemost 1995;74:1185)

Lupus Anticoagulant 

(Hanly JG CMAJ 2003;168(13):1675)

Antiphospholipid Antibodies (aPL) 

• Autoimmune aPL: 

- Persistent 

- Associated with clinical sequelae 

• Infection-related aPL: 

- Transient 

- Not associated with clinical sequelae 

• Routine laboratory assays do not readily 

distinguish between them

Antiphospholipid antibodies 

When to consider 

• Unexplained venous or arterial thrombosis 

• Recurrent fetal loss 

• Thrombocytopenia 

• Hemolytic anemia 

• Systemic lupus erythematosus 

• Prolonged phospholipid dependent 

coagulation test


Classification Criteria (Sapporo) 

• Clinical manifestation: 

- Vascular thrombosis (venous or arterial) 

- Pregnancy morbidity 

3 consecutive losses < 10 weeks gestation 

1 loss 10 weeks gestation 

1 premature births 34 weeks gestation 

• Laboratory criteria: 

- Anticardiolipin antibody (med/high IgG or IgM) 

- Lupus anticoagulant 

(positive test 2 occasions 6 weeks apart) 

(Wilson WA et al. Arthritis Rheum 1999;42:1309)


Modification of Sapporo Criteria 

• Clinical manifestation: 

- Vascular thrombosis (venous or arterial) 

- Pregnancy morbidity 

3 consecutive losses < 10 weeks gestation 

1 loss 10 weeks gestation 

1 premature births 34 weeks gestation 

• Laboratory criteria: 

- Anticardiolipin antibody (med/high IgG or IgM) 


- Anti- 2 -GPI 

(positive test 2 occasions 12 weeks apart) 

(Miyakis et al , J Thromb Haemost, 2006;4:295)


Pathogenic Mechanisms 

(Hanly JG. CMAJ 2003;168(13):1675)



(Hanly JG. CMAJ 2003;168(13):1675)



(Hanly JG. CMAJ 2003;168(13):1675)



(Hanly JG. CMAJ 2003;168(13):1675)



(Hanly JG. CMAJ 2003;168(13):1675)

Blockade of C5a-c5a Receptor Prevents 

aPL Antibody-induced Fetal Loss in Mice 

- Uteri from 15 day pregnancies in mice 

- aPL: antiphospholipid antibody 

- NH-IgG: normal IgG 

- C5aR-AP: C5a receptor antagonistic peptide 

(Girardi G et al, J Clin Invest 112:1644-1654; 2003)

Thrombosis and aPL Antibodies 

• SLE: 

aCL in 12-30% of patients 

LA in 15-34% of patients 

aCl and LA in 38% of pts with aPL 

• Prevalence of thrombosis in SLE patient with aPL: 

50% (venous, arterial, small vessel) 

• Incidence of thrombosis in SLE patient with aPL: 

Two per 100 person years of followup 

(Petri M: Scand J Rheumatol 1996;25:191) 

New event in 7% of pts over 5 years 

(Cervera R et al: Medicine (Baltimore) 1999;78:167)

Thrombosis and aPL Antibodies 

• Recurrent episodes tend to mimic the original 

vascular event 

Venous venous 

Arterial arterial 

• Recurrence in untreated patients: 19–29% per year* 

(*Ruiz-Irastorza, G et al: Arthritis Care & Res 2007; 57:1487)

Recurrent Thrombotic Events 

Initial 

Thrombosis 

Recurrent 

arterial 

thrombosis 

Number (%) 

Recurrent 

venous 

thrombosis 

Number (%) 

Recurrent 

arterial and 

venous 

thrombosis 

Number (%) 

Arterial 11 (85) 1 (8) 1 (8) 

Venous 2 (14) 10 (71) 2 (14) 

(Chopra et al: J Rheumatol 2002;29:1683)

Thrombosis and aPL 

Antibodies 

Factors associated with increased risk: 

- Previous history of thrombosis (esp. arterial) 


- High anticardiolipin antibody levels

Thrombosis and aPL 

Antibodies 

Factors associated with increased risk: 

- Previous history of thrombosis 


- High anticardiolipin antibody levels 

- Traditional risk factors 

(e.g. pregnancy, surgery, OCP) 

- Genetic procoagulant factors ? 

(e.g. Factor V Leiden, Prothrombin)


Thrombotic Manifestations 

• Venous thrombosis 

55% of cases, half of whom have PE 

- Predominantly lower limb 

• Arterial thrombosis 

45% of cases 

- 50% CNS (TIA, stroke) 

- 25% coronary arteries 

- 25% eye, kidney, limb vessels 

(Asherson RA et al: Medicine (Baltimore) 1989;68:366. Alarcon-Segovia D et al: Semin 

Arthritis Rheum 1992;21:275. Vianna JL et al: Am J Med 1994;96:3)

Treatment of APS 

• Obstetric manifestations 

• Thrombotic manifestations

Treatment of Thrombotic 

Manifestations of APS 

Illustrative cases 

Interactive format

Secondary Prevention of 

Thrombotic Events in APS 

• Lifelong anticoagulation following a single 

thrombotic event 

• ASA: no evidence for efficacy 

• Heparin/LMWH Warfarin 

- Mostly retrospective/observational studies 

- Only two RCTs

The Management Of Thrombosis In The 

Antiphopholilipid-antibody Syndrome 

• Retrospective study 

• 147 patients with APS (66 had SLE) 

• 101 (69%) had 186 recurrent thromboses 

• Median time from initial to first recurrence 

was 12 months 

• Examined association with anticoagulant 

treatment 

(Khamashta M et al: N Engl J Med 1995;332:993)

Management Of Thrombosis In APS 

INR ≥ 3 

(Khamashta M et al: N Engl J Med 1995;332:993)

Two Intensities Of Warfarin For The 

Prevention Of Recurrent Thrombosis In 

Patients With APS 

• Randomized clinical trial 

• 114 patients with APS (16 had SLE) 

• Moderate intensity warfarin (INR: 2 – 3) 

• High intensity warfarin (INR: 3.1 – 4) 

• Mean followup: 2.7 years 

• Primary outcome: recurrent thrombosis 

(Crowther M et al: N Engl J Med 2003;349:1133)

A Comparison Of Two Intensities Of Warfarin 

For The Prevention Of Recurrent Thrombosis In 

Patients With APS 

Recurrent 

Thrombosis 

6 (11%) 

2 (3%) 


Two Intensities Of Warfarin For The Prevention 

Of Recurrent Thrombosis in APS 

Study Limitations 

• Exclusions: - 3 months after initial thrombosis 

- prior thrombosis on warfarin 

• 76% patients had hx. of venous thrombosis 

• Low overall event rates for thrombosis 

• Sub-therapeutic INR at time of thrombosis 

Moderate intensity: 1.6, 2.8 

High intensity: 3.1, 1.0, 0.9, 1.9, 3.9, d/c 


A Randomized Clinical Trial Or High-intensity 

Vs. Conventional Antithrombotic Therapy For 

The Prevention Of Patients With The 

Antiphospholipid Syndrome (WAPS) 

Conclusion 

High-intensity warfarin was not superior to standard 

treatment in preventing recurrent thrombosis in 

patients with APS and was associated with an 

increased rate of minor hemorrhagic complications 

(Finazzi, G et al: J Thromb Haemost 2005;3:848)

A Systematic Review Of Secondary 

Thromboprophylaxis In Patients With 

Antiphospholipid Antibodies 

Thrombotic recurrences Hemorrhagic complications 

INR No. % INR No. % 

INR < 3 42 (13A, 16V) 23 INR < 3 24 (5M, 19m) 26 

INR > 3 7 (4A, 1V) 3.8 INR > 3 69 (20M, 49m) 74 

ASA (low dose) 27 (10A, 2V) 15 

No therapy 104 (16A, 42V) 57 

(Ruiz-Irastorza, G et al: Arthritis Care & Res 2007; 57:1487)

Management of Antiphospholipid Antibody Syndrome 

A Systematic Review 

(Lim, W. et al. JAMA 2006;295:1050-1057)

Management of APS 

A Systematic Review 

(Lim, W. et al. JAMA 2006;295:1050-1057)

APASS substudy of WARS 

Patients with cerebral arterial events 

• Study: ASA (low dose) vs Warfarin (INR 1.4-2.8) 

• Major findings: aPL did not predict recurrence 

ASA and Warfarin equal efficacy

Kaplan-meier Analysis Of The Time To Thrombo-occlusive Event, By Apl 

Status Of APASS Patients Receiving Warfarin (N = 881) Or Aspirin (N = 889) 

(APASS Investigators, JAMA 2004;291:576-584)

APASS substudy of WARS 

Patients with cerebral arterial events 

• Study: ASA (low dose) vs Warfarin (INR 1.4-2.8) 

• Major findings: aPL did not predict recurrence 

ASA and Warfarin equal efficacy 

• Limitations: Single measure of aCL (any level) 

LAC testing not optimal 

Mean age 62.5 years 

Females (42%)

A Systematic Review Of Secondary 

Thromboprophylaxis In Patients With aPL 

Recommendations 

• APS first venous event: 

Warfarin, INR:2.0 - 3.0 

• APS recurrent venous event, arterial event: 

Warfarin, INR: > 3.0 

• VTE event and single positive aPL: 

Warfarin, INR: 2.0 - 3.0 

• Stroke and single positive aPL: 

ASA (low dose) 

Similar to 

treatment 

non-SLE 

population 

(Ruiz-Irastorza, G et al: Arthritis Care & Res 2007; 57:1487)

Catastrophic 


• Thrombosis in 3 organ system 

• Rapid onset (“thrombotic storm”) 

• Large and small vessel involvement 

• Kidneys, lungs, CNS, heart and skin most 

common 

• Complicated by DIC in 25% cases 

• Infrequent (

Treatment algorithm for Catastrophic APS 

Bucciarelli S, et al Clinic Rev Allerg Immunol (2009) 36:80–84 

Identify and treat precipitating factors (e.g. infection) 

Life threatening? 

No 

Yes 

Heparin/Steroids 

Heparin/Steroids 

IVIG +/- Plasma exchange 

Clinical improvement? 

Clinical improvement? 

Yes No Yes No 

Steroid taper 

Oral anticoagulant 

Cyclophosphamide 

if SLE flare?

Prevention of Thrombosis in APS 

Other Strategies 

- Hydroxychloroquine 

(Petri M. Lupus 1996; 5 (Suppl 1): S16) 

- Statins (fluvastatin) 

(Ferrara DE, et al. Arthritis Rheum 2003;48:3272) 

(Meroni PL, et al. Arthritis Rheum 2001;44:2870) 

- ACE Inhibitors 

(Napoleone E, et al. Circ Res 2000;86:139) 

- LJP 1082 

(Cockerill K, et al. Arthritis Rheum 2002;46(9):S230) 

- Plamapheresis for catastrophic APS 

(Asherson RA, et al. Medicine (Baltimore) 1998;77:195) 

- Ximelagatran (oral direct thrombin inhibitor) 

(Gustafsson D, et al. Thromb Res 2003;109(1):S9) 

- Avoid procoagulant factors (e.g. OCP)


Summary 

• aPL are a heterogenous group of autoantibodies 

• Detected by ELISA and functional coagulation assays 

• Well defined indications for measuring aPL antibodies 

• Thrombosis and fetal loss major manifestations of APS 

• Multiple pathogenic mechanisms mediated by aPL 

• Anticoagulation mainstay of therapy, but optimum 

management remains controversial


Historical Background (1) 

• Wassermann (1906) 

Sera from patients with syphilis reacted 

with extracts of syphilitic tissues (reagin test) 

• Landsteiner (1907) 

Similar results using healthy human and 

animal tissues ( not due to T. Pallidum) 

• Pangborn (1941) 

Isolated cardiolipin (diphosphatidylglycerol) 

from bovine heart ( antigen in reagin test)



• VDRL test 

Flocculation test using a combination of 

cardiolipin, lecithin and cholesterol 

• T. Pallidum immobilization (TPI) test 

Postive Wassermann reagin test or 

VDRL test not all due to syphilis 

Biologic false positive serologic test 

for syphilis (BFP-STS)



• Moore and Mohr (1952) 

Two types of BFP-STS 

- Transient: acute viral infection 

- Persistent: autoimmune disease 

• Conley and Hartman (1952) 

Prolonged PT and BFP-STS in two 

patients with hemorrhagic disorders 

“lupus anticoagulant”



• Lupus anticoagulant 

- Prolongation of a phospholipid 

dependent coagulation test 

- Associated with in-vivo thrombosis 

- Not confined to patients with SLE 

• Harris et al (1983) 

- Sensitive RIA for aCL antibody detection 

- Subsequent development of ELISA

IgG Anticardiolipin Antibodies

Antiphospholipid Antibodies And Thrombosis

Animal Models of Antiphospholipid Syndrome

Pregnancies In BALB/C Mice Infused With Ig 

Normal Ig 

aCL Ig 

(Piona et al. Scand J Immunol 1996)

Placentae In BALB/C Mice Infused With Ig 

Normal Ig 

aCL Ig 

(Piona et al. Scand J Immunol 1996)

2 -glycoprotein I

2 -glycoprotein I 

• Physiologic role: unknown 

• Role in anticoagulation ? 

• Binds to anionic phospholipids and inhibits: 

- contact phase of intrinsic blood coagulation 

- ADP-dependent platelet aggregation 

- prothrombinase activity of platelets 

• But ……. 

Genetic deficiency = thrombosis 

APS patients have normal levels of 2 -GPI

Annexin V 

(Placental anticoagulant protein I 

Vascular anticoagulant ) 

• Placenta, vascular endothelium, other cells 

• Ca dependent binding to negatively charged 

phospholipids 

• Clusters on phosphatidylserine 

• Displaces phospholipid-dependent 

coagulation factors 

• Potent anticoagulant (in vitro)

Annexin V, Antiphospholipid Antibodies 

and Coagulation 

(Rand JH et al, N Eng J Med 1997;337:154)

Deficiency of C4 or C5 Prevents aPL Antibodyinduced 

Fetal Loss and Growth Restriction 

15 day old fetuses from IgG aPL treated mice 


Inhibition of C5 Activation Prevents aPL Antibodyinduced 

Fetal Loss and Growth Restriction 


TNF- Is a Critical Effector and a Target for Therapy in 

Antiphospholipid Antibody-Induced Pregnancy Loss 

(Berman J et al Journal of Immunology, 174: 485-490, 2005)

Association of Autoantibodies to Nuclear Lamin B1 With 

Thromboprotection in Systemic Lupus Erythematosus 

(Dieude M et al. Arthritis Rheum 2002; 46:2695)

Anti-Lamin B1 Antibodies 

• Apoptotic blebs are procoagulant and a 

source of autoantigens 

• Lamin B1 present within apoptotic blebs 

but internalized and thus not accessible to 

anti-lamin B1 autoantibodies 

• Mechanism of “thromboprotection” unclear


Embolic Manifestations 

• Echocardiographic abnormalities 

- 60% of patients with aPL antibodies 

- Majority of little clinical significance 

- But …. mitral and aortic valve 

vegetations in 4% of patients 

(Vianna JL et al: Am J Med 1994;96:3)

Relative Risk For Pulmonary Embolus And DVT In 

Patients With Anticardiolipin Antibodies 

(Modified from Ginsburg et al., Ann Int Med 1992:117:1000)


Obstetric Manifestations 

• Risk highest following 10 th week gestation 

• Higher risk of prematurity due to pregnancy 

associated hypertension and uteroplacental 

insufficiency

Treatment of APS 

Obstetric Manifestations 

• Prednisone ineffective 

maternal diabetes, hypertension, sepsis 

• Heparin 5,000-10,000 U twice daily SC 

ASA 81-325 mg/day 

• Low molecular weight heparin also used 

Convenience, HIT and osteoporosis 

• Intravenous Ig (1-2 g/kg over 2-5 days) 

adjunctive therapy in resistent cases

Antiphospholipd Syndrome 

and Pregnancy 

• Rai R et al: BMJ 1997;314:253 

90 women; mean fetal losses=4; aPL 

ASA 75 mg/d: 42% live births 

ASA + Heparin 5,000 U SC BID: 71% live births 

• Kutteh WH: Am J Obstet Gynecol 1996;174:15842 

50 women; 3 consecutive fetal losses; aPL 

ASA 81 mg/d: 44% live births 

ASA + Heparin 5,000-20,000 U SC BID: 80% live births

Prevention of Fetal Loss in APS 

Potential Strategies from Animal Experiments 

- Inhibition of complement activation 

(Girardi G et al, J Clin Invest 112:1644-1654, 2003) 

(Thurman JM et al, Mol Immunol 42; 87-97’, 2005) 

- TNF- Inhibition 

(Berman J et al Journal of Immunology, 174: 485-490, 2005)

Acknowledgements 

• John Fisk 

• Connie Hong 

• Stephanie Smith 

• Jody Robichaud 

• Glenda Sherwood 

• Grace McCurdy 

• Lisa Fougere 

• Tina Linehan 

• Jo-Anne Douglas 

• Brian Eastwood 

• Wade Blanchard 

• Kara Thompson 

• Caren Rose 

• Krista Cassell 

• Rheumatologists 

• Dalhousie University 

University Internal Medicine 

Research Foundation (UIMRF) 

Capital Health Research Fund 

• Arthritis Society of Canada 

Ontario Lupus Association 

Medical Research Council (MRC) 

Canadian Institutes for Health 

Research (CIHR)

Antiphospholipid Syndrome.

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