APPENDIX 2 Eight New Cases of LAHS and Review of Literature: Treatment and Follow-Up

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1 Supplementary Digital Content 2 Mazodier Lupus Anticoagulant- Hypoprothrombinemia Syndrome: Report of 8 Cases and Review of the Literature Medicine (Baltimore). 2012;91(5). APPEIX 2 Eight New Cases of LAHS and Review of Literature: Treatment and Follow-Up First Author (year)/ref Lines of Treatment Duration Laboratory Response Delay to Improvement Clinical Outcome Duration of Follow-Up 1. Prednisone 1 mg/kg per d 5 d FII: 42%, PT: rmal, acl and a-β2gp1 2. IVIg 1g/kg per d x 2 d 4 courses (every 6-8 wk) FII: 13%-25% PT: 48%-60% 2 d Case 1/PR 3. Prednisone 15 mg/d then tapered 2 yr FII: 13%, PT: 31% persistent acl Ischemic stroke 8 yr Case 2/PR 4. Rituximab 1 g (J1 J15) LWMH response 5. IVIg x 2 d 2 courses FII: 26%, PT: 47% 2 d 1. Methylprednisone, prednisone 2 mg/kg per d (60 mg) tapering, hydroxychloroquine 2. IV cyclophosphamide + prednisone + hydroxychloroquine 200 mg/d 3 persistent acl IgG 15N, IgM 3N 6 monthly courses FII rmal, PT rmal Persistent LA Persistent acl 10 d Neurologic worsening Hematoma of the arm Death bleeding after 2 d corticodependency Relapse SLE in 2001 membranoproliferative glomerulonephritis 8 yr then azathioprine mo 1

2 Case 3/PR mg/d, salicylic acid 100 mg/d Relapse SLE in 2007 pregnancy 3. Prednisone 30 mg/d, Continue, keep FII rmal, PT rmal hydroxychloroquine, Persistent LA azathioprine 150 mg/d, Persistent acl bleeding thrombosis salicylic acid 100 mg/d Tranexamic Prednisone 40 acid mg/d + 20 d tapered to 5 mg/d + salicylic acid 6 mo FII: 43%, PT: 61% 10 d bleeding thrombosis 3 yr Case 4/PR 1. FFP 2. Transfusion (packed red blood cells) then prednisone 1 mg/kg per d tapered to 20 mg/d 1 yr FII:, PT: 60% decreased PT: 30% FII: 32%, PT: 51% 1 d Erythematous bulbitis anemia 6 g/dl 10 yr Case 5/PR Case 6/PR 3. treatment 1. Oral prednisone 0.5 mg/kg per d (30 mg/d) 2. Prednisone 30 mg/d tapered to 2 mg/d + aspirin 100 mg/d FII: 24%, PT: 40% persistent acl: 27N bleeding thrombosis 6 wk FII 52%, PT 71% 3 wk bleeding after surgery 4 yr FII rmal, PT rmal 6 wk Decreased FII and PT, apl Presurgical test FII rmal, PT rmal Vitamin E, FII:, PT: 52% ticlopidin, 6 yr buflomedil Case 7/PR IVIg 1g/kg per d 2 courses acl IgG: 16 N, a-β2gp1: 10 N FII: 59%, PT: 55% Anti FII positive 15 d Liver carcinoma death 8 yr 10 yr 1 wk 3 yr 2

3 Case 8/PR 1. Fresh frozen plasma, packed red blood cells, IV methylprednisone, then prednisone 50 mg/d FII: 29%, PT: 70% 1 wk 15 mo Rapaport (1960)/[42] Perkins (1960)/[39] 2. Prednisone and mycophenolate mofetil Prednisone 80 mg/d, hydrocortisone 600 mg PT rmal 12 d 2 yr Fatal bleeding death Biggs (1964)/[10] Gonyea (1968)/[21] Prednisone 60 mg 1. Vitamin K + fresh frozen plasma FII: 28%, PT: rmal bleeding at day 6 FII: 47%, PT: rmal 10 mo 10 mo 10 mo Corrigan (1970)/[13] 2. Prednisone 2 mg/kg per d FII: 50%, PT: rmal 3 wk Hematuria stopped at day 2 PT: rmal aptt: rmal Lupus flare and relapse of coagulation abnormalities Corticosteroid tapering. 3 wk 3 wk 2 Bajaj (1983)/[6] 3. Prednisone 2 mg/kg per d FII: 50%, PT: rmal 4 wk 4 wk 4. Azathioprine Nephrotic syndrome thrombophlebitis FII:, PT: rmal aptt: 1.5N Prednisone FII, PT rmal 7 d + azathioprine 125 aptt rmal 12 d 18 d FII normal, 2.5 mo 12 d 3

4 Shaulian (1981)/[46] Follea (1981)/[19] Houbouyan (1984)/[28] Schwartz (1984)/[44] Harrison (1987)/[23] Simel (1987)/[47] Small (1988)/[48] Stormorken (1988)/[49] Baudo (1990)/[7] mg/d Fresh frozen plasma, bleeding at day 6 platelet transfusion, arterial and venous deep thrombosis fibrinogen and pulmonary embolism Fresh frozen plasma + transfusion + fibrinogen Prednisolone 2 mg/kg per d FII: 20%, PT: + azathioprine no response treatment 1. Fresh frozen plasma 2. Prednisone Phenytoin stopped Once bleeding at day 4 aptt: rmal Relapse and corticodependency FII: 24%, PT: rmal a PTT: rmal persistent acl: IgG 4 yr 3 wk bleeding at day 5 1 bleeding 2 1 1/ 1. Fresh frozen plasma Once FII: 48%, PT: 12 d bleeding on postoperative course 1 d FII: 58%, PT: 2. Cyclophosphamide (1g IV) + prednisone 60 mg/d 1. Hydrocortisone 100 mg/8 h tapered to 15 mg/d 7 d relapse after discontinuing prednisone aptt: rmal acl: Corticosteroids 1. Prothrombin concentrate FII:, PT: rmal 2. Prednisone + FII: N, PT: cyclophosphamide 24 d 7 d bleeding bleeding SLE activity Subdural hematoma death 3 1/ 3 yr Hift (1991)/[24] Prednisone 60 mg/d FII: 28%, PT: 1.2 N aptt: 1.5 N 17 d bleeding 8 mo 4

5 Jaeger (1993)/[31] 1. Vitamin K + packed red blood cell transfusion + fresh frozen plasma aptt: rmal acl: neg aptt: rmal Anti-FII: neg aptt rmal Anti-FII neg aptt rmal 4-12 wk Persistent bleeding Bernini (1993)/[9] 2. Methylprednisone 30 mg/kg per d 3 d FII: 16%, PT: 1.2N 3 d bleeding 8 mo Humphries (1994)/[30] 3. Prednisone 2 mg/kg per d 14 d FII: 121%, PT: rmal acl neg FII: 63%, PT: rmal 1. Dexamethasone 7 d FII:, PT: 1.4N 7 d 4 mo 2 yr Peacock (1994)/[37] 2. Prednisone (10 mg/d) 4 mo FII: 59%, PT: rmal aptt: 3N, LA: acl + 4 mo Myocardal infarction death 2 yr Eberhard (1994)/[17] 1. High-dose corticosteroids, packed red blood cells 2. Prednisone + azathioprine Prednisone 60 mg/d aptt: rmal Relapse during Prednisone tapering aptt: rmal, LA: 8 d 8 d 10 d Chorea 20 d Deep venous 25 d 5

6 Lee (1996)/[33] Williams (1996)/[53] Côté (1997)/[14] Becton (1997)/[8] thrombosis Prednisone 60 mg/d coagulation abnormality aptt: rmal 21 d 49 d bleeding at day Prednisone FII rmal, PT 10 d 2. Danazol 600 mg/d 20 d 1. Packed red blood cells 2. Vitamin K, fresh frozen plasma, packed red blood cells aptt: rmal LA: aptt: rmal ACL aptt: rmal acl: aptt: rmal acl neg FII rmal, PT rmal aptt rmal acl neg 108 d Epistaxis Bleeding stopped 18 mo 4 mo 4 mo 60 mo 60 mo 6 mo 48 mo 10 mo 1. Prednisone 30 mg/d FII: 0.27 UI/mL, PT: rmal Chronic bleeding at month 3 Pernod (1997)/[40] 2. IVIg 1g/kg per d 3 d FII: 0.8 UI/mL, PT: rmal 10 d Then prednisone 10 mg/d aptt: 2N, persistent anti FII 10 d acl: 8 mo Prednisone 10 mg/d then no treatment FII: 0.1UI/mL, PT: 1.1N 6 mo bleeding acl: Grau Deflazacort 30 mg/d 7 d 5 mo 6

7 (1997)/[22] Vivaldi (1997)/[52] Deflazacort 30 mg/d then 22.5 mg/d then 15 mg/d 7 d 7 d 5 mo no acl 1. Fresh frozen plasma FII:, INR: d aptt: 3N 2. Prednisolone 1 mg/kg per d + 15 d FII:, INR: d IVIg 0.4 g/kg per d 5 d aptt: 1.6N 5 d 3. Prednisolone 1 mg/kg/j FII:, INR: 1.12 aptt: 1.28 no acl 5 mo bleeding Moll (1997)/[36] FII: 17%, PT: 2.3N acl IgG: 92N Subdural hematoma (5 yr later) 5 yr Hudson (1997)/[29] 1. Transfusion + FII:, PT: high-dose estrogens + a PTT: curetage acl: positive 4 yr 2. Prednisone 40 mg/d + medroxyprogestrone (5 mg/d) 3. Prednisone tapered + oral contraceptives Uterine bleeding 4. Stop oral contraceptives aspirin 325 mg/d Amaurosis fugax at month 3 FII: 27%, PT: 1.4N aptt: 1.4N Severe menorrhagia (3 times during 2 yr) despite increased oral prednisone dose 5. IV methylprednisone 1 g 3 pulses FII: rmal, PT: aptt: rmal 4 d Relapse at day 40 7

8 LA:, acl: 3 d 6. Low dose of prednisone FII: 30% Amiral (1997)/[1] FII: rmal, PT: anti-fii: negative 36 d 1. Antibiotics Relapse at month 2 Epistaxis gum bleeding melena de Larranaga (1999)/[16] FII: 8%, PT: 2.2 N aptt: 4.18N, LA positive acl IgG: 22N anti-fii: 36 N Male (1999)/[35] Erkan (1999)/[18] 2. Prednisone (60 mg/d) 1. Packed red blood cells FII:60%, PT: normal bleeding 3 d a PTT 1.9N, acl IgG 24N, a-β2gp1 IgG: 28N anti-fii: 13N FII: rmal, PT: FII: rmal, PT: FII: rmal, PT: FII rmal, PT FII rmal, PT FII:, PT: rmal aptt: 1.1 N, LA: 7 wk bleeding 6.6 yr 15 d bleeding at day d bleeding at day 6 15 d 1 wk bleeding at day 5 bleeding at day 3 Bleeding stopped at day yr 15 d 1.7 yr 6.3 yr 8

9 2. Methylprednisolone 20 mg/d and prednisone 20 mg/d + hydroxychloroquine 400 mg/d 1. Methylprednisolone (1 g/d) then prednisone 48 mg/d + cyclophosphamide 3 d FII:, PT: rmal aptt: 1.2 N, no acl FII:, PT: 1.1N aptt: 1.1N, acl positive bleeding bleeding 2. Azathioprine + prednisone + hydroxychloroquine 1 yr FII: 30%, PT: 1.1N aptt: 2.2N acl: Arthralgia, gum bleeding, hematuria 14 mo 3. Methylprednisolone 6 mg/d IV FII:, PT: rmal aptt: 1.3 N, LA: Holm (1999)/[27] Ayoub (1999)/[4] Schmugge (2001)/[43] 1. Prednisone + recombinant factor VIIa 1 FII: 0.29 UI/mL, PT rmal 15 minutes bleeding 1. Fresh frozen plasma FII: 0.15 UI/mL, PT: rmal + vitamin K, aptt: rmal Persistent bleeding tranexamic acid 2. Prednisone 1 mg/kg per d 1. Fresh frozen plasma + vitamin K LA:, acl: 4 mo FII: 0.41 UI/mL, PT: rmal aptt: rmal, LA: corticodependency (LA and FII) FII: 20%, PT: 78% aptt: 1.5N, 4 mo 8 d bleeding corticodependency 4 mo 2 yr 2. Tranexamic acid aptt: rmal, anti-fii: negative 156 d Stop bleeding 9

10 1. Prednisone 2 mg/kg per d then tapered 10 d FII:, INR 1.4 aptt:, 10 d Yacobovitch (2001)/[54] 2. Prednisone 20 mg/d aptt:, acl IgG: negative PT: 50%, INR: 3.5 mo Relapse at 6 mo (mild bleeding) 1 yr 3. Hydroxychloroquine FII: 40%-50% 1. Fresh frozen plasma+ packed red blood cells 2. Prednisone 60 mg/d then tapered, prednisone 20 mg/d FII: 24%, PT: 1.3 N aptt: 2N, acl IgG: positive anti-fii: positive Persistent bleeding bleeding Corticodependency 18 mo Baca (2002)/[5] 1. Fresh frozen plasma + packed red blood cells bleeding then relapse 2. Prednisone Stop bleeding 3. Prednisone 7.5 mg/d + azathioprine FII: 1%, PT: 2.25N aptt: 2.4N, acl IgG: 2N, a-β2gp1 IgG: 1.1N anti-fii: 10N bleeding 7 mo Anderson (2003)/[2] 4. Prednisone (45 mg/d), azathioprine 100 mg/d + hydroxychloroquine FII: 1%, PT: 2.85N aptt: 2.4 N, acl IgG: 2.3N, a-β2gp1 IgG: anti-fii: N FII: rmal disappearance of LA bleeding 10

11 Sellami (2004)/[45] 1. Vitamin K + fresh frozen plasma 2. Prednisone 1 mg/kg per d 1. High-dose corticosteroids + aptt:, LA: FII:, PT: 60% FII: rmal, PT: plasma exchange + 2 cycles aptt:, LA: IVIg 1g/kg 2 d Persistent bleeding Splenic infarction Pulmonary embolism regression of cerebellar hematoma 6 mo Vinet (2006)/[51] 2. Prednisone 75 mg/d + cyclophosphamide 2 mg/kg per d + clopidogrel FII: rmal, INR: 1 aptt: 1.7N, later: ischemic stroke secondary to Libmann-Sacks endocarditis under prednisone 75 mg/d, PT normalal 21 yr 3. Prednisone 75 mg/d + azathioprine 2 mg/kg 6 mo + clopidogrel decreased PT on tapered prednisone Taddio (2007)/[50] 4. Tapered prednisone 1.5 yr + cyclophosphamide 2 mg/kg per d + aptt antiplatelet agent 1.5 yr 1. Packed red blood cells, methylprednisone 30 mg/kg per d then prednisone FII: 53%, PT: 3 pulses aptt:, LA: 3 d bleeding or thromboembolic event 6 mo later: SLE relapse (renal) FII corticodependency 18 mo 2. Tapered prednisone FII: rmal + cyclophophamide 0.75 g/m² monthly 11

12 1. Methylprednisolone FII: rmal, PT: IV aptt:, LA: then prednisone decreased FII on tapered + azathioprine prednisone corticodependency 7 yr 2. Cyclophosphamide 0.75 g/m² + tapered prednisone aptt:, LA: acl: rmalization of FII for 7 yr 1. Rituximab 375 mg/m2 (preoperative treatment) Weekly x 4 FII: 0.3 IU/mL, PT: 1.1N 4 wk aptt: 1.5N, LA: acl: Raflores (2007)/[41] 2 wk later FII: 0.78 IU/mL, PT: rmal postoperative bleeding 2. Plasma exchange + 2 aptt: N, LA: IV methylprednisone 500 mg/d 3 d 5 mo 3. Aminocaproic acid (postoperative treatment) 9 d FII: 0.44 IU/mL Day 9 post surgery internal jugular deep venous thrombosis Clauser (2007)/[12] Davey (2007)/[15] 4. IV heparin 5 d Stop quinidine Fresh frozen plasma Chung Fresh frozen plasma, (2008)/[11] prednisone 60 mg/d FII: 59%, PT: rmal aptt: rmal aptt: rmal, no acl FII: 67%, PT: rmal aptt: rmal 5 mo later decreased FII: 0.12 IU/mL 3 yr 1 wk bleeding or thrombosis after surgery 12

13 then tapered FII: 30%, PT: rmal 1 wk and anti-fii Appert-Flory (2010)/[3] treatment and anti-fii 1 yr 1 yr, no anti-fii Abbreviations: a-β2gp1 = anti-β 2-glycoprotein1 antibodies, acl = anticardiolipin antibodies, aptt = activated partial thromboplastin time, INR = international normalized ratio, N = n-times the upper limit of the normal range, = not documented, neg = negative, pos = pos, PR = present report, PT = prothrombin time, SLE = systemic lupus erythematosus, VDRL+/TPHA- = false-positive syphilis serology. 13

APPENDIX 1 Eight New Cases of LAHS and Review of the Literature: Clinical and Laboratory Data

APPENDIX 1 Eight New Cases of LAHS and Review of the Literature: Clinical and Laboratory Data Supplementary Digital Content 1 Mazodier et al. Lupus Anticoagulant- Hypoprothrombinemia Syndrome: Report of 8 Cases and Review of the Literature Medicine (Baltimore). 2012;91(5). APPEDIX 1 Eight ew Cases