APS is an important predictor of mortality in SLE patients

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an 14, 2004

APS is an important predictor of mortality in SLE patients

Bizkaia, Spain - Antiphospholipid syndrome (APS) is a major cause of

morbidity and mortality in patients with systemic lupus erythematosus (SLE),

Spanish researchers have confirmed.

Reporting in the January 12, 2004 issue of the Archives of Internal Medicine

[1], Dr Guillermo Ruiz-Irastorza (Hospital de Cruces, Bizkaia, Spain) and

colleagues say their findings reinforce the recommendation for primary

prevention of thrombosis in patients who have SLE and antiphospholipid

antibodies.

Ruiz-Irastorza, who runs a lupus clinic, told rheumawire: " Most of us in

clinical practice know that APS is 1 of the most important determinants of

progression in lupus, but there have not been many studies that have shown

this. "

The study was also important, he says, because most of the patients with APS

did not receive preventive treatment for thrombosis, " so it's a good

opportunity to look at the natural history of the disease. . . . We found

that most of these patients, if they were left without treatment, would

develop chronic organ damage. "

" We found that most of these patients, if they were left without treatment,

would develop chronic organ damage. "

Currently, all patients with APS are given aspirin therapy of 75 mg to 100

mg per day, Ruiz-Irastorza explained, although a randomized trial is under

way to see if adding warfarin to aspirintitrating to an INR of 1.5-1.8will

be better than aspirin alone. And if patients do suffer a thrombotic event,

the current recommendation is to give warfarin. However, there is some

debate as to whether this should be low-intensity or high-intensity therapy

(see discussion below).

Long-term survival significantly worse in those with SLE and APS

In their cohort of 202 patients with SLE, Ruiz-Irastorza et al found that 28

met the criteria for definite APSdefined as positive anticardiolipin

antibodies and/or lupus anticoagulant plus documented obstetric and/or

thrombotic complications. Mean follow-up was 9.7 years, and irreversible

damagemeasured using the SLE International Collaborating Clinics/American

College of Rheumatology damage index (SDI)was more severe in patients with

APS than in those without (mean SDI score 2 vs 0 at 5 years; p<0.001; 4 vs 1

at 15 years; p<0.001).

Cumulative survival at 15 years was also lower in patients with APS than in

those without (65% vs 90%; p=0.03). Eight patients fulfilled the criteria

for definite APS before dyingin 4 of these, thrombotic events were most

likely the cause of death, the researchers say. Of the remaining 4, 2 died

of cancer, 1 of legionella infection, and 1 committed suicide.

" We found a strong effect of APS on mortality of patients with SLE, "

confirming the results of a previous study [2] published 10 years ago, they

say. And although the patients with APS were only 14% of the total cohort,

" the difference in survival rates seen between groups. . . was high enough

to reach statistical significance. Indeed, APS was identified as an

independent risk factor for mortality, together with age and lupus

nephritis, 2 well-known adverse prognostic variables in lupus. "

" Antiphospholipid syndrome with thrombotic manifestations is a major

predictor of irreversible organ damage and death in patients with SLE, " they

conclude.

Best warfarin regimen for those who have had a thrombotic event?

Last year, a study published in the New England Journal of Medicineas

reported by rheumawireshowed that high-intensity warfarin, with a target INR

of more than 3.0, was not superior to a more moderate target of 2.0 to 3.0

in preventing recurrent thrombosis among patients with APS and previous

thrombosis [3].

" At least some patients with APS should receive high-intensity warfarin

therapy. "

But Ruiz-Irastorza told rheumawire he was not convinced by these resultsmost

of the patients in this study had suffered a venous thrombosis rather than

the more serious arterial thrombosis, he notes. " At least some patients with

APS should receive high-intensity warfarin therapy, " he believes.

" Obviously, I analyze patients on an individual basis, but as a general

rule, if they have suffered an arterial event, I would rather titrate them

to an INR of 3.0 or more, rather than less than 3.0. "

Nainggolan