SLE and the Antiphospholipid Syndrome

Transcription

1 SLE and the Antiphospholipid Syndrome Susan Y. Ritter MD, PhD Associate Physician Division of Rheumatology, Immunology and Allergy Department of Medicine Brigham and Women s Hospital Instructor in Medicine Harvard Medical School

2 Spouse is employee of Pfizer Disclosures

3 Overview SLE different presentations and severity Classification criteria Cutaneous and drug induced Treatment Antiphospholipid Syndrome

4 SLE Epidemiology Prevalence ~1 in 1000 Most common in females in reproductive years 9:1 female : male ratio More common in Black, Latino and Asian

5 What is Lupus? Great imitator Many different organ-systems may be involved Disease occurs in the presence of autoantibodies most commonly ANA

6 Many faces of SLE 51 yo white male glomerulonephritis (GN), + ANA, + dsdna, seizures 32 yo black female arthritis, discoid rash, pleurisy, + ANA, + Ro 52 yo female thrombocytopenia, hemolytic anemia, renal disease, +ANA, + APLA 27 yo female fevers, class V GN, low WBC, + ANA, + dsdna, low complements, arthritis

7 What is shared? Positive autoantibodies Clinical manifestations suggestive of SLE

8 Classification Criteria for SLE 4 are necessary, and 1 should be + ANA Malar Rash Discoid Rash Photosensitivity Apthous ulcers Neurologic: seizures or psychosis Hematologic: anemia, leuko or lymphopenia, thrombocytopenia Arthritis Serositis (pericarditis or pleuritis) Immunologic: anti-dna, anti- Smith, antiphospholipid antibody Positive ANA Renal (proteinuria or casts)

9 Other common symptoms Fatigue Headaches Malaise Cognitive impairment lupus fog Myalgias

10 Case 1 33 yo woman comes to see you. She has mouth sores and a rash over the bridge of her nose that looks like this:

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13 Case 1: continued Her PCP sent off an ANA that was positive at a titer of 1:320 and she had dsdna at 45 units. Does she have SLE?

14 Case 1: Malar rash Photosensitivity Aphthous ulcers Positive ANA Positive anti-dsdna

15 Other skin manifestations of SLE

16 Discoid lupus

17 Cutaneous Lupus: Discoid Lupus Patient have defined plaques that become thickened over time. Can scar and leave hypopigmented lesions 10-15% of patients develop systemic lupus in those that are ANA positive In SLE patients, 10-15% will have discoid lesions Treatment: sun avoidance, antimalarials, dapsone, immunosuppressive agents, thalidomide

18 Cutaneous Lupus: SCLE (subacute cutaneous lupus erythematosus) More common in Caucasians 75% are women Lesions occur in sun-exposed areas Two types of lesions: Papulosquamous Polycyclic annular

19 SCLE

20 Other Skin Findings in SLE Alopecia Vasculitis Raynaud s Bullous lesions Urticarial lesions Panniculitis Nail lesions

21 Alopecia

22 Raynaud s

23 Case 2 40 yo man whom you have been following for several years with SLE (malar rash, positive serologies and renal disease) complains of chest pain when he takes a deep breath Is this related to lupus?

24 Pulmonary Manifestations of SLE Pleuritis Lupus pneumonitis Chronic interstitial lung disease Pulmonary hemorrhage (high mortality) Shrinking lung syndrome (secondary to diaphragmatic paralysis and lung disease)

25 Case 3 35 yo female whom you have followed for SLE for many years (joint symptoms, renal disease, positive serologies, requiring steroids) has read on the internet that she is at risk for having a heart attack How do you counsel her?

26 Cardiovascular Manifestations of SLE Accelerated atherosclerosis Disease + drugs Pericarditis Valvular heart disease usually in conjunction with the antiphospholipid syndrome Coronary vasculitis rare Myocarditis rare

27 Case 4 32 yo woman referred from her PCP with one month of joint swelling affecting her PIPs and MCPs. She has a history of psoriasis and her PCP believes she has psoriatic arthritis.

28 Case 4: continued Despite being placed on NSAIDs and low dose steroids, she continues to feel unwell. Calls your office with fevers 102, feels terrible Initial labs reveal a WBC 2.8. You decide to send off an ANA which returns at 1:1280 and dsdna is 84.

29 Jaccoud s arthropathy

30 Musculoskeletal manifestations of SLE 95% will have musculoskeletal complains Arthralgias and arthritis Septic arthritis Osteonecrosis risk increases with steroid use > 20 mg per day Myositis more commonly seen in patients with Mixed Connective Tissue Disease (MCTD) Myopathy secondary to steroids proximal muscle weakness

31 Case 5 25 yo woman referred to you with anemia and thrombocytopenia Hemocrit 25 Platelet count 90,000 She has a history of pleuritis Positive ANA and false positive VDRL

32 Hematologic manifestations of SLE Anemia usually Coomb s positive Leukopenia WBC < 4000 Lymphopenia Lymphocytes < 1500 Thrombocytopenia Platelets < 100,000

33 Case 6 29 yo woman with history of mild SLE (arthritis, malar rash, positive serologies) presents with edema, proteinuria, and RBC in her urine What do you do?

34 Renal disease in SLE Proteinuria > 500 mg protein/24 hr urine Presence of casts

35 WHO Classification Class I: Normal or Minimal Change Class II: Mesangial glomerulonephritis Class III: Focal proliferative glomerulonephritis Class IV: Diffuse proliferative glomerulonephritis Class V: Membranous glomerulonephritis Class VI: Global sclerosis > 90% sclerosed lesions

36 Activity vs. Chronicity Look for the degree of activity in the involved renal specimen High disease activity implies better response to therapy Chronic lesions are scarred, and will not improve with immunosuppression

37 Case 7 25 yo woman with history of SLE (hematologic and arthritis) presents with altered mental status

38 Neuropsychiatric Manifestations of SLE Neurologic CVA Seizures Transverse myelitis Optic neuritis Meningitis Headaches Organic brain syndromes Neuropathies Associated with antiphospholipid antibodies Psychiatric Psychosis Cognitive disorder Pseudo dementia Functional

39 Other SLE manifestations Sjogren s Syndrome GI abnormalities Abdominal pain Anorexia Peritonitis Pancreatitis Hepatitis Secondary fibromyalgia

40 Case 8 You are asked to see a 38 yo woman with a history of a rash over the bridge of her nose which she has been told is acne rosacea and some joint achiness She has an ANA sent that is positive at 1:40 Does she have lupus?

41 Few notes about ANA test ANA test was not designed as a screening test Up to 20% of healthy adults, particularly women, have a low titer ANA and do not go on to develop rheumatic diseases Causes of false positive tests: viral infections family history of rheumatic disease other autoimmune disease like GI or thyroid disease Once a patient has a positive ANA, it does not need to be retested, unless symptoms change and there is an increased suspicion for a rheumatic disease.

42 Autoantibodies in SLE ANA found in 95% of patients Anti-dsDNA in 40-80% of patients Anti-Sm 25% of patients Anti-histone seen in drug induced SLE Anti-Ro(SSA), Anti-La(SSB) Sjogren s, SCLE Anti-RNP Mixed Connective Tissue disease False positive VDRL antiphospholipid antibody

43 Choosing Wisely Campaign Don t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease. Tests for anti-nuclear antibody (ANA) sub-serologies are usually negative if the ANA is negative. Exceptions include anti-jo1, which can be positive in some forms of myositis, or occasionally anti-ssa, in the setting of lupus or Sjögren s syndrome. Broad testing of autoantibodies should be avoided; instead the choice of autoantibodies should be guided by the specific disease under consideration.

44 Case 9 63 yo man started on procainamide for an abnormal heart rhythm. He develops joint pain and a skin rash Work-up reveals a positive ANA and anti-histone antibody

45 Drug Induced SLE Patients present with lupus-like illness Usually arthritis, rash and serositis Positive ANA and anti-histone antibody Rare to have renal, neuropsychiatric or vasculitic disease Often responds to drug withdrawal, NSAIDs or low dose prednisone

46 Drugs Involved in Drug-Induced SLE

47 Drugs Involved in Drug-Induced SLE Common Procainamide Hydralazine Rare Beta-blockers D-Penicillamine INH Quinidine PTU Hydantoins Trimethadione Chlorpromazine

48 General Treatment Advice in SLE Sun avoidance and protection Diet Exercise Smoking cessation

49 Lupus Flare A flare is a measurable increase in disease activity in one or more organ systems involving new or worse clinical signs and symptoms and/or laboratory measurements. It must be considered clinically significant by the assessor and usually there would be at least consideration of a change or an increase in treatment. International consensus for a definition of disease flare in lupus. Ruperto et al. Lupus Apr;20(5):

50 Treatment: Mild Disease Symptoms: low grade fever, rash, arthralgia, fatigue NSAIDs Antimalarials hydroxychloroquine most common Low dose prednisone < 10 mg/day

51 Treatment: Severe Disease Steroids: mg/kg/day renal, CNS Cyclophosphamide monthly pulses mg/m2 or biweekly for 12 weeks renal, CNS Azathioprine renal Mycophenolate mofetil renal, skin Tacrolimus renal, skin Methotrexate arthritis, skin Belimumab steroid resistant serositis and arthritis

52 Other therapies (off label) Cyclosporine A Rituximab Abatacept joint symptoms, in trials for renal disease Bone marrow transplant

53 Summary of SLE SLE is a multi-system autoimmune disorder SLE can look like many different disease entities To diagnose SLE, the ANA should be positive A positive ANA dose NOT make a diagnosis of SLE Direct treatment towards the underlying system involved All patients unless contraindicated should be offered hydroxychloroquine Can use steroids and other immunosuppressives Biologics other than belimumab are under investigation

54 Antiphospholipid Antibody Syndrome

55 When to think about antiphopholipid antibodies? Early miscarriages Thrombocytopenia Stroke/TIA in younger patients DVT/PE Patients with lupus

56 Antiphospholipid Antibody Syndrome: Major criteria Presence of an anticardiolipin antibody (IgG or IgM) and/or lupus anticoagulant on 2 separate occasions 12 weeks apart PLUS one of the following clinical events: Arterial thrombotic event Venous thrombotic event Recurrent pregnancy losses 2 or more 1 st trimester losses 2 nd trimester loss or severe intrauterine growth restriction

57 Other clinical features (not part of criteria) Thrombocytopenia Coomb s positive hemolytic anemia Livedo reticularis Raynaud s phenomenon Migraines and cognitive dysfunction Valvular vegetations or thickening Renal disease thrombotic microangiopathy

58 Associated medical conditions Sneddon s syndrome: Strokes and livedo reticularis in young women Evan s syndrome: Thrombocytopenia and Coomb s positive hemolytic anemia CVAs and MIs in individuals under 40 SLE Catastrophic APS (CAPS) sudden multisystem occlusive disease

59 Antiphospholipid Antibody Tests Lupus Anticoagulant Anti-Cardiolipin Beta-2 glycoprotein I

60 Lupus Anticoagulant In vitro prolongation of clotting test In vivo it is a pro-coagulant Activated PTT, platelet neutralizing procedure, dilute Russell Viper Venom time are used Lupus anticoagulant should be confirmed by adding phospholipid and normalizing the test result

61 3 Possibilities Lupus Anticoagulant Confirmatory What dose it mean? - Negative + - Negative + + Positive

62 Anticardiolipin Antibodies ELISA test: standardized using international standard GPL units All subsets: IgG, IgM, IgA, IgD can be seen, but IgG is the most clinically relevant Clinically relevant titer is 40 units

63 Anti-beta-2 glycoprotein I ELISA test IgG and IgM forms Clinically relevant titer is 40 units drvvt (used with LAC) is sensitive to the presence of anti-beta-2-glycoprotein I Closely correlated with thrombotic events

64 Antibodies in Various Patient Populations Healthy controls: 1-2% Recurrent miscarriage population: 5-10% SLE: 20-40% SLE with livedo or Raynaud s: 80% Stroke, MI under age 40: 20% HIV infected: IgM 50-60%

65 Who should be evaluated for antiphospholipid antibodies? SLE patients Patients under age 40 with CVA, MI, no obvious risk factors Recurrent venous or arterial clots Women with recurrent first trimester pregnancy losses, or second trimester loss

66 Treatment: Patients with documented clot + antibodies Lifelong anticoagulation generally warfarin Target INR 2.5 Recurrent episodes, severe arterial episodes, target INR There is insufficient data regarding the efficacy of direct oral anticoagulants in this condition.

67 Treatment: Antibodies in the absence of clinical events Some advocate the use of prophylactic aspirin therapy in those with positive antibodies. This therapy has NOT been shown to decrease the risk of clotting episodes except in patients with co-existing SLE

68 Catastrophic Antiphospholipid Syndrome (CAPS) Consider when multiple clots over 7 days Renal failure, diffuse alveolar hemorrhage, adrenal hemorrhage, encephalopathy can be seen Can look similar to other thrombotic microangiopathies Treatment with anticoagulants, corticosteroids, IVIG and plasma exchange Some use Rituximab or Eculizumab (off label) if refractory

69 Summary of APS The antiphosholipid syndrome is defined as: Arterial clots, venous clots or obstetrical complications in the presence of an antiphospholipid antibody The antibody testing needs to be positive on 2 separate occasions at least 12 weeks apart Treatment for the arterial or venous complications is life-long anticoagulation

70 Question 1 23 F with a history of malaise, facial rash and achiness. Appropriate work-up includes: A) ANA B) CBC w/ diff, LFTs, creatinine and urinalysis C) dsdna D) All of the above

71 Answer B) CBC, LFTs, renal function screen As a first pass for the evaluation of suspected SLE, a complete history and physical should be performed. Appropriate laboratory testing includes a CBC with differential, liver function tests, creatinine and urinalysis. Avoid sending an ANA and/or dsdna unless there is a strong suspicion of SLE.

72 Question 2 43 F presents with a DVT with no clear precipitant. PMHx is notable for 2 first trimester miscarriages and one second trimester miscarriage. Appropriate testing includes: A) Lupus anti-coagulant B) Anticardiolipin antibody C) VDRL D) A, B, and C E) A and B only

73 Answer E) A and B should be sent The history is suggestive of antiphospholipid syndrome Send off both the lupus anticoagulant and anticardiolipin antibody when you have a high suspicion for the antiphospholipid antibody syndrome VDRL is not a good screening assay for this disorder

74 References Classification criteria for systemic lupus erythematosus: a review. Petri M, Magder L. Lupus. 2004;13(11):829 Guidelines for referral and management of systemic lupus erythematosus in adults. American College of Rheumatology Ad Hoc Committee on Systemic Lupus Erythematosus Guidelines. Arthritis Rheum Sep; 42(9): Diagnosis and Management of the Antiphospholipid Syndrome. Garcia D and Erkan D. NEJM May 24; 378 (21):