Yiannis Ioannou

Outcome of a cohort of 300 patients with systemic lupus erythematosus attending a dedicated clinic for over two decades

Objective: To examine the mortality rate and causes of death in a cohort of 300 patients with systemic lupus erythematosus (SLE). Methods: A retrospective analysis was performed on all patients attending the SLE clinic between 1978 and 2000. Information was obtained on those patients lost to follow up. Cause of death was analysed and categorised as early (<5 years after diagnosis of SLE) and late (>5 years after diagnosis of SLE). Standardised mortality rates were obtained. Results: The patients were followed up for a median of 8.3 years. Seventy three (24%) patients were no longer followed up at the end of the study period, of whom 41 (14%) had died. Of the 32 patients lost to follow up, 14 were being actively followed up within the UK, 16 were followed up outside the UK, and two patients were untraceable. The most common cause of death was malignancy, which accounted for eight (20%) deaths, followed by infection and vascular disease, which accounted for seven (17%) deaths each. Conclusions: Malignancy was the most common cause of death. Cause of death varied depending on disease duration. Forty per cent of early deaths were due to SLE related renal disease, whereas 23% of late deaths were due to vascular causes. Death due to infection occurred throughout the follow up period. There was a fourfold increased risk of death in our cohort of patients with SLE compared with the general population.

In vivo inhibition of antiphospholipid antibody‐induced pathogenicity utilizing the antigenic target peptide domain I of β2‐glycoprotein I: proof of concept

Summary.  Objectives: In the antiphospholipid syndrome (APS), the immunodominant epitope for the majority of circulating pathogenic antiphospholipid antibodies (aPLs) is the N‐terminal domain I (DI) of β2‐glycoprotein I. We have previously shown that recombinant DI inhibits the binding of aPLs in fluid phase to immobilized native antigen, and that this inhibition is greater with the DI(D8S/D9G) mutant and absent with the DI(R39S) mutant. Hence, we hypothesized that DI and DI(D8S/D9G) would inhibit aPL‐induced pathogenicity in vivo. Methods: C57BL/6 mice (n = 5, each group) were injected with purified IgG derived from APS patients (IgG‐APS, 500 μg) or IgG from normal healthy serum (IgG‐NHS) and either recombinant DI, DI(R39S), DI(D8S/D9G), or an irrelevant control peptide (at 10–40 μg). Outcome variables measured were femoral vein thrombus dynamics in treated and control groups following standardized vessel injury, expression of vascular cell adhesion molecule‐1 (VCAM‐1) on the aortic endothelial surface, and tissue factor (TF) activity in murine macrophages. Results: IgG‐APS significantly increased thrombus size as compared with IgG‐NHS. The IgG‐APS thrombus enhancement effect was abolished in mice pretreated with recombinant DI (P ≤ 0.0001) and DI(D8S/D9G) (P ≤ 0.0001), but not in those treated with DI(R39S) or control peptide. This inhibitory effect by DI was dose‐dependent, and at lower doses DI(D8S/D9G) was a more potent inhibitor of thrombosis than wild‐type DI (P ≤ 0.01). DI also inhibited IgG‐APS induction of VCAM‐1 on the aortic endothelial surface and TF production by murine macrophages. Conclusion: Our findings in this proof‐of‐concept study support the development of recombinant DI or the novel variant DI(D8S/D9G) as a potential future therapeutic agent for APS.

Novel Assays of Thrombogenic Pathogenicity in the Antiphospholipid Syndrome Based on the Detection of Molecular Oxidative Modification of the Major Autoantigen β2-Glycoprotein I

Objective Beta-2-glycoprotein I (β2GPI) constitutes the major autoantigen in the antiphospholipid syndrome (APS), a common acquired cause of arterial and venous thrombosis. We recently described the novel observation that β2GPI may exist in healthy individuals in a free thiol (biochemically reduced) form. The present study was undertaken to quantify the levels of total, reduced, and posttranslationally modified oxidized β2GPI in APS patients compared to various control groups. Methods In a retrospective multicenter analysis, the proportion of β2GPI with free thiols in serum from healthy volunteers was quantified. Assays for measurement of reduced as well as total circulating β2GPI were developed and tested in the following groups: APS (with thrombosis) (n = 139), autoimmune disease with or without persistent antiphospholipid antibodies (aPL) but without APS (n = 188), vascular thrombosis without APS or aPL (n = 38), and healthy volunteers (n = 91). Results Total β2GPI was significantly elevated in patients with APS (median 216.2 μg/ml [interquartile range 173.3–263.8]) as compared to healthy subjects (median 178.4 μg/ml [interquartile range 149.4–227.5] [P < 0.0002]) or control patients with autoimmune disease or vascular thrombosis (both P < 0.0001). The proportion of total β2GPI in an oxidized form (i.e., lacking free thiols) was significantly greater in the APS group than in each of the 3 control groups (all P < 0.0001). Conclusion This large retrospective multicenter study shows that posttranslational modification of β2GPI via thiol-exchange reactions is a highly specific phenomenon in the setting of APS thrombosis. Quantification of posttranslational modifications of β2GPI in conjunction with standard laboratory tests for APS may offer the potential to more accurately predict the risk of occurrence of a thrombotic event in the setting of APS.

Measuring IgA Anti-β2-Glycoprotein I and IgG/IgA Anti-Domain I Antibodies Adds Value to Current Serological Assays for the Antiphospholipid Syndrome

Introduction Currently available clinical assays to detect antiphospholipid antibodies (aPL) test for IgG and IgM antibodies to cardiolipin (aCL) and β2-glycoprotein I (aβ2GPI). It has been suggested that testing for IgA aPL and for antibodies to Domain I (DI), which carries the key antigenic epitopes of β2GPI, could add value to these current tests. We performed an observational, multicenter cohort study to evaluate the utility of IgG, IgM and IgA assays to each of CL, β2GPI and DI in APS. Methods Serum from 230 patients with APS (n = 111), SLE but not APS (n = 119), and 200 healthy controls were tested for IgG, IgM and IgA aCL, aβ2GPI and aDI activity. Patients with APS were further classified into thrombotic or obstetric APS. Logistic regression and receiver operator characteristic analyses were employed to compare results from the nine different assays. Results All assays displayed good specificity for APS; IgG aCL and IgG aβ2GPI assays however, had the highest sensitivity. Testing positive for IgA aβ2GPI resulted in a higher hazard ratio for APS compared to IgM aβ2GPI. Positive IgG, IgM or IgA aDI were all associated with APS, and in subjects positive for aCL and/or aβ2GPI, the presence of aDI raised the hazard ratio for APS by 3–5 fold. IgG aCL, aβ2GPI, aDI and IgA aDI were associated with thrombotic but not obstetric complications in patients with APS. Conclusion Measuring IgG aDI and IgA aβ2GPI and aDI may be useful in the management of patients with APS, particularly thrombotic APS.

B cell depletion therapy for patients with systemic lupus erythaematosus results in a significant drop in anticardiolipin antibody titres

Background: B cell depletion therapy (BCDT) has recently been used with success to treat patients with rheumatoid arthritis and systemic lupus erythematosus (SLE). As antiphospholipid antibodies have been implicated in the pathogenesis of the antiphospholipid syndrome (APS), we asked the question whether BCDT affects levels of IgG anticardiolipin antibodies (aCL) in our cohort of 32 SLE patients given this treatment. Methods: We identified seven SLE patients who had undergone BCDT and had had at least two moderate positive aCL titres at least 12 weeks apart. Of these only one patient had APS. IgG aCL were measured at time 0 and 6–9 months post BCDT. Results: At time 0, the mean IgG aCL level was 20.6 standardized IgG antiphospholipid units (GPLU) (range (SD) 10–32, (10.1), normal level <5). At 6–9 months post depletion the IgG aCL levels in six of the seven patients was undetectable and in the other patient the level reduced from 25 GPLU to 15 GPLU (p<0.005, two-tailed paired t test). At baseline, only one patient had a mildly positive anti-β2-glycoprotein I (β2GPI) antibody level at 30% (compared to an in-house standard), which fell to 5% post-BCDT. Conclusions: This small observational study in patients with SLE is the first to demonstrate that BCDT results in a significant reduction in levels of IgG aCL.

Immunisation of patients with systemic lupus erythematosus: the current state of play.

Concerns regarding the safety and efficacy of immunisation in patients with SLE have persisted for over 50 y and indeed infection remains a leading cause of morbidity and mortality in these patients. There have been many anecdotal reports in the literature linking vaccination with either induction or exacerbation of SLE disease. However prospective studies have shown that immunisation with inactivated/killed vaccines is probably safe in patients with SLE. Individuals on immunosuppressive agents and/or high dose steroid (more than 20 mg/d) should not receive live vaccines, as stated in guidelines proposed by the British Society of Rheumatology. The safety of hepatitis B vaccination in patients with SLE is as yet undetermined and a prospective study is required. However until such evidence becomes available the advice of the BSR should be followed and patients with SLE who are at risk of exposure should be vaccinated. It remains uncertain whether the immune response to immunisation is significantly impaired by active disease and/or immunosuppressive treatment and to what extent. Most patients do however seem to mount a satisfactory immune response though this may not be quantitatively and qualitatively the same as healthy controls.

Examining the prevalence of non-criteria anti-phospholipid antibodies in patients with anti-phospholipid syndrome: a systematic review

OBJECTIVE To systematically review and establish the prevalence of antibody positivity in assays not currently included in the APS classification criteria to detect antibodies directed against other phospholipids (PLs), PL binding proteins, coagulation factors and a mechanistic test for resistance of Annexin A5 (AnxA5) anticoagulant activity in APS and control populations. METHODS We searched PubMed and EMBASE using the key words APS, antiphospholipid antibodies, non-criteria, new assays, IgA anticardiolipin antibodies, lupus anticoagulant, anti-Domain I, IgA anti-β2-glycoprotein I antibodies, antiphosphatidylserine, anti-phosphatidylethanolamine, anti-phosphatidic acid, antiprothrombin, antiphosphatidylserine-prothtombin, anti-vimentin/cardiolipin complex and Annexin A5 resistance. Studies that met inclusion criteria to describe prevalence of non-criteria aPLs in APS patients (n > 10), disease and healthy control subjects were systematically examined. RESULTS We selected 16 retrospective studies of 1404 APS patients, 1839 disease control and 797 healthy controls. The highest prevalence of non-criteria aPLs in the largest number of patients with APS was found in IgA anti-β2GPI studies (129/229, 56.3%), AnxA5R (87/163, 53.4%) and IgG anti-Domain I (241/548, 44.0%). CONCLUSION Our finding of a significantly high prevalence of all non-criteria aPLs studied in patients with APS compared with controls was tempered by wide variation in sample size, retrospective collection, assay methodology and different determination of positivity. Therefore, prospective studies of sufficient size and appropriate methodology are required to evaluate the significance of these assays and their utility in the management of patients with APS.

Antibodies to domain I of β-2-glycoprotein I and IgA antiphospholipid antibodies in patients with ‘seronegative’ antiphospholipid syndrome

The standard serological tests included in the classification criteria1 for antiphospholipid syndrome (APS) are those to detect immunoglobulin G (IgG) and IgM antibodies to cardiolipin (aCL) or β-2-glycoprotein I (anti-β2GPI) and the lupus anticoagulant. It is increasingly recognised, however, that some patients have typical thrombotic and non-thrombotic features of APS but test repeatedly negative in these routinely used assays. It has been suggested that these patients have the so-called seronegative APS (SN-APS).2 In a retrospective study, there were no significant differences in clinical manifestations between 87 patients with seropositive APS and 67 with SN-APS.3 Several authors have suggested that in these ‘seronegative’ patients, clinically relevant antibodies can be detected by looking for different isotypes, particularly IgA2 and/or different antigen specificity4 or by using different techniques4 ,5 than those of the routine assays. In a recent …

PEGylated drugs in rheumatology—why develop them and do they work?

Lack of efficacy and drug-related adverse effects are important reasons for the discontinuation of treatment in patients with rheumatic diseases. The development of new biologic therapies seeks to address these problems by specifically targeting the pathogenic mechanisms of disease. Most current biologics are proteins (particularly antibodies and enzymes) administered parenterally. It is important to optimize properties such as serum half-life, immunogenicity and solubility. Companies have thus begun to modify the drugs by conjugate chemistry, binding inert molecules such as polyethylene glycol (PEG) to biologic molecules to improve their pharmacodynamic properties. The use of PEG to alter these properties has to be weighed against the negative aspects of PEGylation, such as decreased activity and heterogeneity. This review focuses on the currently available PEGylated drugs used in rheumatological diseases, their efficacy, drawbacks and the current clinical trial evidence supporting their use.

Mucocutaneous manifestations in a UK national cohort of juvenile-onset systemic lupus erythematosus patients

OBJECTIVE To determine whether mucocutaneous manifestations are associated with major organ involvement in a UK national cohort of juvenile-onset SLE (JSLE) patients. METHODS JSLE patients (n = 241) from 15 different centres whose diagnosis fulfilled four or more of the ACR criteria were divided into two groups: those with at least one ACR mucocutaneous criterion (ACR skin feature positive) and those without (ACR skin feature negative) at diagnosis. The relative frequency of skin involvement was described by the paediatric adaptation of the 2004 British Isles Lupus Assessment Group (pBILAG-2004) index. RESULTS One hundred and seventy-nine patients (74%) had ACR-defined skin involvement with no significant demographic differences compared with those without. ACR skin feature negative patients showed greater haematological (84% vs 67%), renal (43% vs 26%) (P < 0.05) and neurological (16% vs 4%) involvement (P = 0.001). Forty-two per cent of ACR skin feature negative patients had skin involvement using pBILAG-2004, which included maculopapular rash (17%), non-scaring alopecia (15%), cutaneous vasculitis (12%) and RP (12%). ACR skin feature negative patients with moderate to severe skin involvement by pBILAG-2004 showed greater renal and haematological involvement at diagnosis and over the follow-up period (P < 0.05). Higher immunosuppressive drug use in the skin feature negative group was demonstrated. CONCLUSION Patients who fulfil the ACR criteria but without any of the mucocutaneous criteria at diagnosis have an increased risk of major organ involvement. The pBILAG-2004 index has shown that other skin lesions may go undetected using the ACR criteria alone, and these lesions show a strong correlation with disease severity and major organ involvement.