La sindrome da aPL : up to date La sindrome da aPL : up to date PL - - PowerPoint PPT Presentation

La sindrome da aPL : up to date La sindrome da aPL : up to date

PL Meroni

• Div. of Rheumatology, Dept. Clinical Sciences &

Community Health, Univ. of Milan, Ist. G Pini – Milan

Classification criteria for APS Classification criteria for APS

– Vascular thrombosis: > 1 episode – Pregnancy morbidity:

• Abortions (<10 sem.): > 3
• Fetal death (>10 sem.): > 1
• Prematures (<34 sem.): > 1

– – aCL (IgG/IgM): > 2 determ. (med/high titre) – Anti-β β β β2GPI (IgG/IgM) : > 2 determ. (med/high titre) – LAC: > 2 determ. Clinical criteria Clinical criteria Laboratory criteria Laboratory criteria Classification: 1 clinical criteria + 1 laboratory criteria Classification: 1 clinical criteria + 1 laboratory criteria

Myiakis et al JTH ‘06

Classification Diagnostic criteria Classification Diagnostic criteria

aPL assays

Specificity/ Predictive value Sensitivity aCL + +++ Anti-β β β β2GPI ++ ++ LAC +++ +

LA activity is mediated by different autoaAbs

Exner T, Blood Coagul Fibrinolysis 5: 281-289, 1994.

95%

2/3 anti-prothrombin 2/3 anti-prothrombin 1/3 anti-b2GPI

5%

autoAbs against

• ther PL-binding

proteins

Protein C Protein S Factor V (Kapur A 1993) ………………. ………………. (Oosting GD 1993)

Anti-PT Abs can be detected by the PS-PT assay An additional formal classification lab tool?

PL PL-

• binding proteins bound by autoAbs in the

binding proteins bound by autoAbs in the solid solid-

• phase assays

phase assays

Bovine Bovine β β β β β β β β2GPI 2GPI Anionic PL Anionic PL aCL assay aCL assay Human Human β β β β β β β β2GPI 2GPI γ γ γ γ γ γ γ γ-

• irr.plates

irr.plates anti anti-

• β

β β β β β β β2GPI assay 2GPI assay Human prothrombin Human prothrombin Anionic PL (PS) Anionic PL (PS) Anti Anti-

• PT assay

PT assay Protein C, Protein S Protein C, Protein S and C4b and C4b-

• binding protein

binding protein Activated Protein C Activated Protein C Anionic PL Anionic PL aCL assay +/ aCL assay +/-

• Thrombomodulin

Thrombomodulin Anionic PL Anionic PL aCL assay +/ aCL assay +/-

• Annexin V

Annexin V Anionic PL Anionic PL aCL assay +/ aCL assay +/-

• High molecular weight kininogen

High molecular weight kininogen Neutral PL (PE) Neutral PL (PE) anti anti-

• PE assay

PE assay

β2GPI-mediated LA more strongly correlated with thrombosis than anti-PT mediated LA Domain I anti-β2GPI Abs confer LA activity with the highest risk for thrombosis

De Laat et al. Blood ‘04 Devreese et al. Blood ‘10

Anti Anti-

• β

β β β β β β β2GPI domain I autoAbs 2GPI domain I autoAbs De Laat et al Curr Rheumatol Rep ‘11

* Human anti-β β β β2GPI MoAb reacts with DI Same reactivity with: a)INOVA DI plates (Mahler et al Autoimmun Rev ‘12) b)39-43 aa peptide DI epitope (Ioannou et al Lupus ‘10)

MoAb & murine β2GPI MoAb & human β2GPI Irr MoAb &murine β2GPI Irr MoAb & human β2GPI

20 40 60 80 100 120

MBB2 MB unrelated

Fetal resorption frequency (%)

0,5 1 1,5 2 2,5 3 3,5 4

MBB2 MB unrelated

fetal weight (g)

A B C

P = 0.0049 P = 0.0286

D

MoAb MoAb MoAb Irr MoAb Irr MoAb

Anti Anti-

• DI hu MoAb is pathogenic

DI hu MoAb is pathogenic

• DE Laat et al Blood ’05. IgG antibodies that recognize epitope

Gly40-Arg43 in domain I of beta 2-glycoprotein I cause LAC, and their presence correlates strongly with thrombosis.

• De Laat B et al JTH ’09 : IgG against D1 of β2GPI more strongly

associated with thrombosis/obstetric complications than those detected by the standard anti-β2GPI Ab assay.

• De Angelis et al Lupus (Abst)‘10: solid phase assay for D1. Anti-

D1 Abs seem specific for APS pats but not associated with increased risk of arterial thrombosis in the general population.

• Andreoli et al ARD ’10: Children born to mothers with systemic

autoimmune disorders or children with atopic dermatitis display preferential IgG reactivity for D4/5, whereas APS patients are mainly positive for D1.

• Banzato et al. Thromb. Res. ‘11 Antibodies to domain I of

beta(2)glycoprotein I are in close relation to patients risk categories in antiphospholipid syndrome (APS).

Anti-DI – IV/V in our series

(58 PAPS sera and 15 aPL carriers) % pos

Whole β2GPI Whole β2GPI/D IV-V Whole β2GPI/D I Triple negative D IV-V 21% 41% 21% 9% 4% 4%

Autoantibodies to Domain 1 of Beta 2 glycoprotein 1: A promising candidate biomarker for risk management in antiphospholipid syndrome

• M. Mahler, G.L. Norman, P.L. Meroni, M. Khamashta

2012 , 12:313-17

Take home messages

The hypothesis of anti-β2GP1-D1 antibodies as promising biomarker in diagnosis /risk assessment of APS is scientifically sound, but needs further verification Efforts are needed to standardize assays to detect β2GP1-D1 antibodies Prospective, multi-centric, longitudinal studies are necessary to clearly define the clinical utility of anti- β2GP1-D1 antibodies

Main therapeutic targets

Vascular Avoiding recurrences Obstetric Preventing comorbidities: APS nephropathy, cognitive dysfunction(?), atherothrombosis.

Treatment of vascular APS Treatment of vascular APS manifestations manifestations

Risk Risk-

• stratification

stratification

aPL autoAb profile Test Triple positivity LA Isotype IgG > IgM Titer Medium/high titer

Higher risk

Age, diabetes, arterial hypePA, dyslipidemia, BMI, smoking, sedentary lifestyle, hyperhomocyst, Protein C, Protein S and ATIII deficiency , Factor V Leyden, PT and MHTFR mutations

Concomitant thrombotic risk-factors Underlying autoimmune diseases

Venous events Venous events

Oral anticoagulant therapy Oral anticoagulant therapy

• INR target:

INR target:

Standard intensity (INR 2.0-3.0) High intensity (INR 3.1-4.0)

Crowther MA, N Engl J Med 2003 Finazzi G, J Thromb Haemost 2005

versus

Limitations: Patients with history of recurrent thrombosis were excluded Patients in the high intensity group had an INR below the target 40% of the follow-up time

Very low frequency of recurrent events in both trials within all groups

• Duration of anticoagulation:

Duration of anticoagulation:

Indefinitely Indefinitely 3 3-

• 6 months

6 months

versus

The highest rate of recurrent thrombosis occurs in APS patients who had withdrawn their anticoagulants within the preceding 6 months.

Khamashta, N Engl J Med 1995

aPL positivity at least doubles the risk for recurrent disease. Mandatory in high-risk patients

Ruiz-Irastorza G, Lupus 2011

Arterial events Arterial events

Standard Intensity Standard Intensity anticoagulation anticoagulation + + Antiplatelet agent Antiplatelet agent High Intensity High Intensity anticoagulation anticoagulation Antiplatelet Antiplatelet agent agent Standard Intensity anticoagulation Standard Intensity anticoagulation

Higher efficacy of high-intensity anticoagulation in preventing reccurrent thrombosis Khamashta MA,N Engl J Med

1995

Recurrence rate over a 6-year period of 30% in patients in standard intensity anticoagulant Pengo V, J Thromb Haemost 2010 Recurrent thromboses infrequent when INR > 3.0

Ruiz-Irastorza G, Arthritis Rheum 2007; Tan BE, Lupus 2009

• Recommended treatment

Recommended treatment Ruiz-Irastorza G, Lupus 2011 No differences between aspirin and standard intensity anticoagulation for secondary stroke prevention

APASS, 2004

• Recommended in patients without SLE and low

Recommended in patients without SLE and low-

• risk aPL profile

risk aPL profile

Ruiz Ruiz-

• Irastorza G, Lupus 2011

Irastorza G, Lupus 2011

Standard intensity anticoagulation more effective than low-dose aspirin and no therapy Pengo V, J Thromb Haemost 2010 Standard intensity anticoagulation not inferior to high intensity anticoagulation in preventing recurrency

Crowther MA, N Engl J Med 2003; Finazzi G, J Thromb Haemost 2005

Lower incidence of recurrent stroke compared to aspirin (cumulative stroke-free survival: 74 versus 25% Okuma H, Int J Med Sci

2009

• Recommended treatment

Recommended treatment

Ruiz-Irastorza G, Lupus 2011

Consider also: Consider also: Higher bleeding risk when rising anticoagulation intensity Bleeding risk in APS: 0.57-10% per year

Ruiz-Irastorza G, Arthritis Rheum 2007

Higher difficulties in keeping INR in the 3.1-4.0 than in the 2.0-3.0 range

Crowther MA, N Engl J Med 2003

Anticoagulant Agents Anticoagulant Agents

Oral Vitamin K Antagonists

Oral Vitamin K Antagonists

warfarin acenocoumarol

• UFH/LMWH

UFH/LMWH

• Fondaparinux

Fondaparinux

• New Oral Anticoagulant Agents

New Oral Anticoagulant Agents

dabigatran rivaroxaban apixaban

Limits:

Slow onset of action of 3-5 days Narrow therapeutic window Drugs and dietary interaction INR monitoring LA intereference on PT-INR

Ongoing prospective randomised controlled phase II/III clinical trial

Limits:

SC administration Heparin-induced thrombocytopenia Osteoporosis

Limits:

SC administration

Refractory Cases Refractory Cases

Increase of target therapeutic dose Substitution of oral VKA by s.c. therapeutic LMWH Addition of low dose aspirin Addition of hydroxychloroquine

Modulation of aPL-induced platelet activation / anti- thrombotic activity Inhibition of the formation of aPL-β2GPI-PL bilayer complexes

Full anticoagulation (i.v. heparin 1500 U/h) Steroids (1-2 mg/Kg daily) IVIg Plasma Exchange + Fresh Frozen Plasma

In case of schistocytes Anti-C5moAb (eculizumab)

Asherson RA, Lupus 2003

Catastrophic APS Catastrophic APS

FIRST LINE FIRST LINE SECOND LINE SECOND LINE

Treatment of obstetric APS Treatment of obstetric APS manifestations manifestations

APS without previous thrombosis: APS without previous thrombosis:

Low dose aspirin Low dose aspirin + + LMWH at thromboprophylactic dose LMWH at thromboprophylactic dose

(Stop 12 hours before and resume 6 to 8 hours

after hepidural anaesthesia)

Up to 6 weeks after delivery

APS with previous thrombosis: APS with previous thrombosis:

Low dose aspirin Low dose aspirin + + LMWH at therapeutic dose LMWH at therapeutic dose

(Stop 12 hours before and resume 6 to 8 hours after hepidural anaesthesia)

Shift to VKA in the puerperium

Low dose aspirin Low dose aspirin

10% reduction of the risk of aPL-related complications as compared to placebo Stephenson MD, J Obstet Gynecol Can 2004 Decrease of the miscarriage risk in aPL+ women when administered preconceptionally Noble LS, Fertil Steril 2005

Heparin Heparin VKAs VKAs

Teratogenic effects between the 6°and the 10°WG High risk of bleeding after the 12° WG

Refractory Cases Refractory Cases

Therapeutic LMWH dose Therapeutic LMWH dose

Erkan D, Rheumatology 2008

• Corticosteroids

Corticosteroids

No benefit in pregnant women with APS Increase in serious pregnancy complications (mainly prematurity and hypertension)

Lockshin MD, Am J Obstet Gynecol 1989 Silver RK, Am J Obstet Gynecol 1993 Cowchock FS, Am J Obstet Gynecol 1992

Significant improvement in pregnancy outcome with the addition to the ASA+LMWH regimen of Prednisone 10 mg daily up to week in 18 APS women not responsive to standard treatment

Live birth rate 61% in the PDN+ASA+LMWH group

Bramham K, Blood 2011

• Plasma Exchange

Plasma Exchange

Anecdotal Reports

Ruffatti A, Autoimmun Rev 2007 Bortolati M, Ther Apher Dial 2009 Bontadi A, J Clin Apheresis 2012

BUT BUT

• IVIg

IVIg

IVIg not superior to heparin + aspirin:

Lower live birth rate in the IvIg group compared to the group treated with heparin plus aspirin

Dendrinos S, Int J Gynaecol Obstet 2009 Triolo G, Arthritis Rheum 2003

Case-reports of positive outcomes when IVIg added added to standard treatment

Bortolati M, Ther Apher Dial 2009 Bontadi A, J Clin Apheresis 2012

Our experience with IVIg Our experience with IVIg… …

BUT BUT

6 Pregnancies in 4 APS women refractory to conventional treatme 6 Pregnancies in 4 APS women refractory to conventional treatment nt

IVIg 400 mg/Kg 4 days/month IVIg 400 mg/Kg 4 days/month POSITIVE OUTCOMES POSITIVE OUTCOMES IN ALL 6 PREGNANCIES IN ALL 6 PREGNANCIES

Mean delivery week: 36 36° ° (34 (34-

• 38)

38) Mean birth weight: 2530 gr (1950 2530 gr (1950-

• 3080)

3080)

Management of aPL asymptomatic Management of aPL asymptomatic carriers carriers

APLASA study: APLASA study: Low dose aspirin not more effective than placebo for primary prevention of vascular events

Management of aPL asymptomatic carriers Management of aPL asymptomatic carriers Primary thrombophrophylaxis? Primary thrombophrophylaxis?

Low rate of vascular events

• Unselected aPL carriers

Unselected aPL carriers

NO TREATMENT NO TREATMENT Aspirin Aspirin Hydroxychloroquine Hydroxychloroquine

aPL carriers aPL carriers

• with inherited causes of thrombophilia

with inherited causes of thrombophilia

• with underlying autoimmune conditions

with underlying autoimmune conditions

• during puerperium

during puerperium

High rate of vascular events

Potential new therapeutic targets

Giannakopoulos & Krilis NEJM ‘13 NAC, VitC, Coe-Q10 NFκ κ κ κB, p38MAPK

Statins HCQ C’ blocking Ag competition B cell drugs Receptor inhibition Inhib

Rituximab Rituximab

Case reports, case series Case reports, case series RITAPS RITAPS trial trial

21 cases described in literature up to August 2009

Venous thrombosis: 16 patients Arterial thrombosis: 8 patients Thrombocytopenia: 11 patients CAPS: 5 patients Autoimmune hemolytic anemia: 4 patients Vasculitis: 4 patients

• Severe thrombocytopenia

Severe thrombocytopenia: : no response Cardiac valve vegetation: Cardiac valve vegetation: improvements in 2 out

• f 3 patients on echocardiography
• Skin ulcers

Skin ulcers: improvement in 2 out of 5 patients

Resolution of APS Resolution of APS clinical manifestations clinical manifestations in 19 cases in 19 cases

19 patients with APS non-criteria manifestations

• aPL nephropathy:

aPL nephropathy: partial response (1 case) No substatial changes in aPL titres Good safety profile of Rituximab in APS

Erkan D, Arthritis Rheum 2013 Kumar D, Curr Rheumatol Rep 2010

BUT…

Two episodes of severe acute thrombotic exacerbations (lacunar infarctions and transverse myelitis) in two APS/SLE patients treated with Rituximab

Suzuki K, Rheumatology 2008

!

BAFF blockade: in vivo evidences BAFF blockade: in vivo evidences

(NZW X BXSB) F1 mice BAFF-R-Ig

No prevention of aCL development

aCL generated in the germinal centre

Prevention of aPL thrombotic vasculopathy

Single dose of adenovirus expressing BAFF-R-Ig

Belimumab as next therapeutic option in APS? Belimumab as next therapeutic option in APS?

Potential new therapeutic targets

Giannakopoulos & Krilis NEJM ‘13 NFκ κ κ κB, p38MAPK

Ab competition PL binding site competition

TIFI and β β β β2GPI-dependent aPL binding to cell membranes

• TIFI: 20 aa synthetic peptide (from CMV) sharing similarity with the

β2GPI PL-(membrane) binding region. TIFI binds anionic PL; is not recognized by aPL; displaces β2GPI from cell surfaces, inhibiting in vitro binding of FITC-β2GPI to EC and monocytes.

• TIFI reduced aPL-mediated thrombosis and EC activation in vivo (Vega-

Ostertag et al, Lupus ‘06) FITC-β2GPI 50 µg/ml + TIFI 20 µg/ml FITC-β2GPI 50 µg/ml + TIFI 5 µg/ml

Human anti Human anti-

• β

β β β β β β β2GPI moAb (IS3) binding to 2GPI moAb (IS3) binding to trophoblast cells trophoblast cells

Irr moAb + β2GPI IS3 + β2GPI IS3 + TIFI + β2GPI

aPL aPL-

• induced fetal loss:

induced fetal loss: more than one more than one model, more than one mechanisms model, more than one mechanisms

• Repeated passive injection of large amounts
• f aPL IgG (10 mg/mouse) after implantation

(Holers et al JEM ’02; Girardi et al JCI ’03; Redecha et al Blood ‘07)

• One shot passive infusion of small amounts

One shot passive infusion of small amounts

• f aPL IgG (10
• f aPL IgG (10 –

– 50 50 µ µ µ µ µ µ µ µg/mouse) after g/mouse) after mating/before implantation mating/before implantation (Piona et al Sc J Immunol ’94;

Ichikawa et al A&R ’98; Martinez e al PNAS ‘07)

TIFI TIFI -

• but not the irrelevant peptide (VITT)

but not the irrelevant peptide (VITT) – – inhibits aPL inhibits aPL-

• induced

induced fetal loss in pregnant naive fetal loss in pregnant naive C57BL/6 C57BL/6 mice mice

20 40 60 80 100 120

MBB2 MBB2∆CH2

Fetal resorption frequency (%)

0,05 0,1 0,15 0,2 0,25 0,3 0,35

MBB2 MBB2∆CH2

fetal weight (g)

P = 0.0008 P = 0.0141

B C

C’ non fixing hu anti-DI moAb C’ + C’ -- C’ + C’ --

C’ non fixing anti-DI hu moAb recognizes murine & human β β β β2GPI but it is not pathogenic

C’ + moAb C’ neg moAb

C’ non fixing anti-DI moAb displaces polyclonal IgG anti-β β β β2GPI and is protective

Aknowledgments

Borghi MO Pierangeli SS Raschi E University of Texas Chighizola C Grossi C Gerosa M University of Milan Tedesco F Mahler M University of Trieste Inova, S Diego

• Children born to mothers with systemic

autoimmune disorders or children with atopic dermatitis display preferential IgG reactivity for D4/5, whereas APS patients are mainly positive for D1.

Andreoli et al ARD ’10

No signs of overt inflammation are evident in the labyrinth (L) and the junctional zone (jz). A few leukocytes and focal areas of mild necrosis (**) are detected in the maternal site of placenta (decidua basalis, db), with no difference among groups.

Venn diagram representing number of genes differentially expressed comparing aPL vs NHS, aPL vs aPL+TIFI and aPL+TIFI vs NHS treated mice (A). Over-represented biological processes related to differentially expressed genes identified by GO categories enrichment in aPL vs NHS (filled columns) and aPL vs aPL+TIFI (open columns) comparisons (B).

• In vivo inhibition of aPL-induced

thrombosis (pinch model) by infusing the antigenic target peptide domain I

• f β2-glycoprotein I: proof of concept.

Ioannou, Y. et al JTH ‘09

Mating 1st week 2nd week 3° week Sacrifice aPL IgG 50 mg/mouse (Piona et al Sc J Immunol ’94; Ichikawa et al A&R ’98; Martinez e al PNAS ‘07)