review
Pathogenesis and management of antiphospholipid syndrome
Deepa R.J. Arachchillage and Mike Laffan
Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, London,
UK
Summary
Antiphospholipid antibodies are a heterogeneous group of
autoantibodies that have clear associations with thrombosis
and pregnancy morbidity, and which together constitute the
‘antiphospholipid syndrome’ (APS). However, the patho-
physiology of these complications is not well understood and
their heterogeneity suggests that more than one pathogenic
process may be involved. Diagnosis remains a combination
of laboratory analysis and clinical observation but there have
been significant advances in identifying specific pathogenic
features, such as domain I-specific anti-b2-glycoprotein-I
antibodies. This in turn has pointed to endothelial and com-
plement activation as important factors in the pathogenesis
of APS. Consequently, although anticoagulation remains the
standard treatment for thrombotic APS and during preg-
nancy, the realisation that these additional pathways are
involved in the pathogenesis of APS has significant implica-
tions for treatment: agents acting outside the coagulation
system, such as hydroxychloroquine for pregnancy complica-
tions and sirolimus as an inhibitor of the mammalian target
of rapamycin (mTOR) pathway, are now under evaluation
and represent a radical change in thinking for haematolo-
gists. Conventional anticoagulation is also under challenge
from new, direct acting anticoagulants. This review will pro-
vide a comprehensive overview of the evolving understanding
of APS pathogenesis and how this and novel therapeutics will
alter diagnosis and management.
Keywords: antiphospholipid antibodies, thrombosis, war-
farin, pregnancy complications, complement, immunosup-
pression.
Antiphospholipid syndrome (APS) is characterized by vascu-
lar thrombosis and/or pregnancy loss or morbidity in associ-
ation with persistent positivity of autoantibodies known as
Correspondence: Dr Deepa RJ Arachchillage, Department of
haematology, Imperial College Healthcare NHS Trust and Imperial
College London,, Hammersmith Hospital, 4th Floor, Commonwealth
Building, Du Cane Road, London W12 0NN, UK.
E-mail: d.arachchillage@imperial.ac.uk
ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
antiphospholipid antibodies (aPL) (Miyakis et al, 2006)
(Table I). Vascular thrombosis can be arterial, venous, or
small vessel, in any tissue or organ and must be objectively
confirmed (i.e. unequivocal findings of appropriate imaging
studies or histopathology). Thrombosis in APS should show
no signs of inflammation in the vessel wall (Miyakis et al,
2006). Although many patients with APS have an associated
autoimmune disorder, thrombotic events in APS are not
accompanied by histological evidence of vessel wall inflam-
mation. Nonetheless, inflammatory mediators and inflamma-
tory responses in endothelial cells, monocytes and
neutrophils are implicated in APS pathogenesis. The Interna-
tional Consensus Criteria (ICC: Sydney; updated Sapporo)
for APS (Miyakis et al, 2006) were designed for scientific
clinical studies but have been adapted for the diagnosis of
APS in routine clinical practice. The British Committee for
Standards in Haematology (BCSH) guidelines (Keeling et al,
2012) adopt similar criteria for the diagnosis of both throm-
botic and obstetric APS. Non-criteria features of APS, such
as heart valve disease, livedo reticularis, thrombocytopenia
and nephropathy, may present in association with thrombo-
sis and/or pregnancy morbidity or as isolated features. The
APS Clinical Features Task Force of the 14th International
Congress on aPL analysed the relevance of the most frequent
non-criteria manifestations and concluded that available data
support the inclusion of thrombocytopenia, heart valve dis-
ease, renal microangiopathy (aPL nephropathy), chorea, and
longitudinal myelitis as part of the APS Classification Criteria
(Abreu et al, 2015). However, these features are not yet
included in the ICC. APS can occur in isolation or in associ-
ation with other autoimmune disorders, such as systemic
lupus erythematous (SLE) or rheumatoid arthritis (Miyakis
et al, 2006).
Antiphospholipid antibodies are a heterogeneous group of
autoantibodies, which include lupus anticoagulant (LA),
immunoglobulin (Ig)G and IgM anticardiolipin antibodies
(aCL) and anti-b2-glycoprotein-I (anti-b2GPI) antibodies.
Their primary targets are phospholipid-binding proteins,
although antibodies directed against phospholipids and other
proteins also occur. In the early 1950’s Conley and Hart-
mann (1952) wrote a brief report describing two patients
with SLE and a ‘peculiar haemorrhagic disorder’ with pro-
longed blood clotting times and clear evidence of an
doi: 10.1111/bjh.14632
Review
Table I. The international consensus (revised Sapporo) criteria for diagnosis of obstetric antiphospholipid syndrome.
Clinical criteria
1 One or more unexplained deaths of a morphologically normal
fetus at or beyond the 10th week of gestation
2 One or more pre-term births of a morphologically normal neonate
before the 34th week of gestation because of:
(i) eclampsia or severe pre-eclampsia or
(ii) recognized features of placental insufficiency
3 Three or more unexplained consecutive spontaneous miscarriages
before the 10th week of gestation, with maternal anatomic or
hormonal abnormalities and paternal and maternal
chromosomal causes excluded
OAPS is diagnosed if at least one of the clinical criteria and one of the laboratory criteria are met
aCL, anticardiolipin antibodies; anti-b2GPI, anti-b2glycoprotein-I antibodies; GPL, IgG antiphospholipid units; LA, lupus anticoagulants; MPL,
IgM antiphospholipid units; OAPS, Obstetric antiphospholipid syndrome.
anticoagulant in plasma mixing studies. As this inhibitor was
predominantly found in patients with SLE, the in vitro anti-
coagulant phenomenon was called LA. The paradoxical cor-
relation between vascular thrombosis and LA was first
described by Bowie et al (1963) and was followed by many
others. Originally, it was thought that these autoantibodies
bound to phospholipid; hence ‘antiphospholipid antibodies’
but in the 1990s it was shown that aPL recognized phospho-
lipids indirectly via phospholipid-binding plasma proteins
(Galli et al, 1990). Although many plasma proteins have been
found to be antibody ligands in APS, antibodies against
b2GPI have the most significant association with pathogenic-
ity (Bas de Laat et al, 2004). Some authors have challenged
the primacy of anti-b2GPI antibodies in the pathogenesis of
APS (Lackner & M€ uller-Calleja, 2016) and shown that some
co-factor independent antibodies can induce thrombus for-
mation in a mouse model (Manukyan et al, 2016).
The laboratory diagnosis of APS requires the presence of
LA in plasma or aCL of IgG and/or IgM isotype in serum or
plasma, present in medium or high titre (i.e. >40 IgG
antiphospholipid units [GPL] or IgM antiphospholipid units
[MPL], or >the 99th centile) or anti-b2GPI of IgG and/or
IgM isotype in serum or plasma (in titre >the 99th centile).
The positive results must be obtained on two or more occa-
sions, at least 12 weeks apart (Miyakis et al, 2006). Inter-
laboratory variability remains a problem in the performance
of the aCL and anti-b2GPI enzyme-linked immunosorbent
assays (ELISAs) due to the lack of uniformity in reference
materials for calibration.
Nonetheless, identification of these antibodies has allowed
development of diagnostic testing and investigation of patho-
genic mechanisms. These in turn offer additional therapeutic
options, which are currently under investigation. Even con-
ventional anticoagulant therapy is under review while the
role of direct acting oral anticoagulants is investigated. The
2 ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
Laboratory criteria
1 LA present in plasma, on two or more occasions at least 12 weeks
apart
2 aCL of immunoglobulin (Ig)G and/or IgM isotype in serum or
plasma, present in medium or high titre (i.e. >40 GPL units or
MPL units, or > the 99th centile), on two or more occasions,
at least 12 weeks apart
3 anti-b2GPI of IgG and/or IgM isotype in serum or plasma
(in titre >the 99th centile), present on two or more occasions at
least 12 weeks apart
key events in APS are summarised in Fig 1. The aim of this
review is to examine the evolving understanding of APS
pathogenesis and how this and other therapeutic options will
change the way we manage this potentially devastating disor-
der.
Pathogenesis of Antiphospholipid syndrome
Despite clear associations between aPL and thrombosis and
with pregnancy morbidity, the pathophysiology of these
complications is not well understood, with their heterogene-
ity suggesting that more than one pathogenic process is
involved. Moreover, even though aPL are persistently present
in the systemic circulation, thrombotic events occur only
occasionally, suggesting that the development of aPL is a
necessary, but not sufficient step in the development of APS
and that other factors play a role. Such ‘second hits’ or ‘trig-
gers’ probably push the thrombotic/haemostatic balance in
favour of thrombosis and may include infection, endothelial
injury, inflammation, immunological and other non-immu-
nological procoagulant factors, such as oestrogen-containing
contraceptive pills, surgery and immobility (Pengo et al,
2011). The patient’s genetic constitution, in relation to genes
for inflammatory mediators, may also be a critical variable in
the development of clinical APS manifestations.
Antibody specificities and evidence for pathogenicity of
anti-b2-GPI
Mcneil et al (1990) found that the binding of aPL to cardi-
olipin requires the presence of b2GPI as a cofactor. b2GPI is
an apolipoprotein, a member of the complement control
family and is considered to be a natural inhibitor of coagula-
tion. In addition, in vitro studies have shown that it has anti-
angiogenic (Yu et al, 2008) and anti-apoptotic (Maiti et al,
 Review

Fig 1. Key events in the history of Antiphospholipid syndrome (Adapted from figure originally drawn by Prof. Mike Greaves, with permission).
APS, antiphosphlipid syndrome; DOACs, direct acting oral anticoagulants; SLE, systemic lupus erythematosus.

Fig 2. Schematic representation of folded (cir-

cular) and unfolded conformation of beta2 gly-
coprotein I (b2GPI) and subsequent binding to
anti-b2GPI antibodies (Adapted from van Os
et al, 2011). In the presence of anionic phos-
pholipids, the circular conformation of the
protein unfolds, exposing antigenic determi-
nants that are normally shielded from the cir-
culation (A–C) which facilitate the binding to
antibodies (D).

2008) activities. It consists of 326 amino acids, arranged in 5
highly homologous complement-control protein domains
that are designated I to V from the N- to the C-terminus.
b2GPI can adopt two different conformations: a circular con-
formation in plasma, maintained by interaction between the
first and fifth domain and an ‘activated’ open conformation
(Agar et al, 2010). In the presence of anionic phospholipids,
the circular conformation of the protein unfolds, exposing
antigenic determinants that are normally shielded from the
circulation (van Os et al, 2011) [Fig 2]. One of these ‘cryptic’
antigenic determinants, within domain I (DI), is the epitope
for the pathological autoantibodies (de Laat et al, 2006;
Ioannou et al, 2007); which will not bind to the closed circu-
lating form. Unfolding of b2GPI on the endothelial surface
may be facilitated by release of molecules, such as thiore-
doxin, in response to oxidative stress, which can reduce sur-
face thiols on b2GPI. Binding of b2GPI on endothelial cells
(EC) normally has a protective function against oxidative
stress-induced cell injury (Ioannou et al, 2010, 2011) but
antibody binding fixes b2GPI in this open conformation on
the phospholipid surface and the antibody-b2GPI complexes
bind to a variety of receptors (e.g., Toll-like receptors 2 and
4, annexin A2 and GP1ba) on different cell types, including
ECs, monocytes, trophoblasts and platelets (de Groot &

ª 2017 John Wiley & Sons Ltd, British Journal of Haematology 3

Review
Meijers, 2011). This binding may trigger intracellular sig-
nalling and inflammatory responses.
Direct evidence for the pathogenicity of these antibodies
comes from infusion of autoantibodies from APS patients to
mice with injured blood vessels showing that they potentiate
thrombus formation (Arad et al, 2011). Specifically, purified
anti-b2GP1 IgG autoantibodies, but not anti-b2GPI depleted
IgG or normal human IgG, potentiated thrombus size in a
dose-dependent manner. Although several clinical studies
and systematic reviews suggested that LA is a stronger risk
factor for the development of thrombosis (Galli et al, 2003;
de Groot et al, 2005), other studies have shown that the
presence of LA alone is not associated with thromboembolic
events (Pengo et al, 2005; Pengo et al, 2007). Similar results
were obtained in the Leiden Thrombophila case–control
study (de Groot et al, 2005) where positive LA with negative
anti-b2GPI or antiprothrombin ELISAs was not a risk for
deep vein thrombosis (DVT [odds ratio (OR) 1
3, 95% con-
fidence interval (CI): 0
3–6
0]. However, a recent systematic
review and meta-analysis found that LA and aCL antibodies
were associated with an increased risk of venous thromboem-
bolism (VTE) [OR = 6
14 (CI 2
74; 13
8) and OR = 1
46 (CI
1
06; 2
03) respectively] but there was a non-significant trend
for anti-b2GPI (OR = 1
61 (CI 0
76; 3
43)] (Reynaud et al,
2014). For arterial thrombosis, all three antibodies showed a
significant association: ORs for LA, aCL and anti-b2GPI were
3
58 (CI 1
29–9
92), 2
65 (CI 1
75–4
00) and 3
12 (CI 1
51–
6
44) respectively (Reynaud et al, 2014). de Laat et al (2004)
found that anti-b2GPI antibodies with LA activity are
responsible for the thromboembolic complications in APS
(de Laat et al, 2004). Moreover, they showed that a subgroup
of anti-b2GPI recognizing epitope Gly40-Arg43 (G40-R43) in
DI of the molecule cause LA and that their presence corre-
lates strongly with thrombosis (de Laat et al, 2005). This has
been confirmed by various other studies (de Laat et al, 2009;
Pengo et al, 2015).
Consequently, these pathogenic antibodies will only bind
purified b2GPI when coated onto an appropriate negatively-
charged surface and this has important implications for the
design, selection and significance of diagnostic assays (de
Laat et al, 2005, 2006). It has been shown that exposure of
the critical DI epitope G40-R43 on b2GPI is highly variable
between commercial anti-b2GPI assays. As a consequence,
false negatives can arise in assays characterized by a reduced
exposure of G40-R43 (Pelkmans et al, 2013).
The presence of triple aPL positivity, as defined by the
detection of LA and high titres of aCL and anti-b2GPI anti-
bodies, correlates better with both thrombosis and pregnancy
morbidity than any other aPL profile (Pengo et al, 2010): the
risk of recurrent thrombosis in triple positive patients was
around 30% over a 6-year follow-up period (Pengo et al,
2010). Triple-positive patients also have high titres of
autoantibodies that bind the major B-cell epitope on DI of
the b2GPI molecule (Banzato et al, 2011). Thus anti-DI-
b2GPI autoantibodies confer LA activity associated with the
4 ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
highest risk of thrombosis (de Laat et al, 2009), frequently
present in triple aPL-positive patients, are closely associated
with both thrombosis and pregnancy loss (de Laat et al,
2009) and increase thrombus size in mouse models (Peri-
cleous et al, 2015). Of note, about 30% of patients with anti-
b2GPI antibodies are negative for anti-DI–b2GPI antibodies
(Pengo et al, 2015) and the clinical significance of autoanti-
bodies reacting with epitopes other than DI was investigated
in a multicentre study (Artenjak et al, 2015). This study
analysed serum samples from 201 autoimmune patients with
IgG anti- b2GPI activity (87 APS, 67 APS plus SLE and 47
with SLE only) for their binding to six b2GPI peptides corre-
sponding to amino acid clusters on domains I-II, II, III and
III-IV. The results showed a diverse clinical association with
reactivity to different epitopes on b2GPI, suggesting all
domains were relevant. Therefore, more detailed profiling of
domain specificity and avidity of anti-b2GPI antibodies may
be useful as risk stratification for clinical events.
Studies using cell cultures demonstrated that monocytes,
ECs and platelets can also be activated by aPL with anti-
b2GPI activity inducing the expression of intercellular cell
adhesion molecule-1 (ICAM-1), vascular cell adhesion mole-
cule-1 (VCAM-1) and E-selectin on EC, and of tissue factor
(TF) on both EC and monocytes (Pierangeli et al, 2008).
Activated platelets increase expression of GPIIbIIIa and syn-
thesis of thromboxane A2 (Pierangeli et al, 2008). However,
it is possible that cells in culture may not behave as they do
in vivo.
Non- criteria antibodies
The role of so-called non-criteria antibodies, such as anti-
phosphatidylserine/prothrombin, anti-phosphatidic acid,
anti-vimentin/cardiolipin complex anti-protein C/S and a
variety of other autoantibodies with specificities, such as fac-
tor XII, factor X, Annexin A5 and Annexin A2, in the patho-
genesis and diagnosis of APS remains to be established. The
role of anti-DI-b2GPI antibodies in pathogenesis of APS is
discussed above. A small cross-sectional study demonstrated
that anti-protein C antibodies are associated with resistance
to endogenous protein C activation and a severe thrombotic
phenotype in APS (Arachchillage et al, 2014). Several studies
have analysed the role of the IgA isotype of aPL. In particu-
lar, the pathogenicity of IgA aPL was established by demon-
strating that mice, injected with IgA aPL from patients with
APS, developed thrombosis (Pierangeli et al, 1995). In a
recent systematic review to establish the prevalence of non-
criteria antibodies and of resistance to Annexin A5 anticoag-
ulant activity (AnxA5R) in APS and control populations, 16
retrospective studies of 1404 APS patients, (1839 disease con-
trols and 797 healthy controls) were examined (Rodriguez-
Garcia et al, 2015). It was found that IgA anti-b2GPI anti-
bodies (129/229, 56
3%) were most prevalent, followed by
AnxA5R (87/163, 53
4%) and IgG anti-Domain I (241/548,
44
0%) (Rodriguez-Garcia et al, 2015). However, in addition

to the retrospective data collection, the results were affected
by wide variation in the sample size, discrepancy in assay
methodology and the different cut-off levels used for assay
positivity. Prospective multicentre studies with adequate
sample size using more uniform methodology are essential to
determine the implications of these antibodies for the man-
agement of APS.
Pathogenic mechanisms involving other pathways
There is evidence from several animal models that comple-
ment activation, with excess C3a and C5a generation, plays a
role in thrombotic manifestations in APS. Complement acti-
vation contributes to vascular inflammation and complement
inhibition may ameliorate aPL-induced thrombosis, offering
a potential new approach to therapy (Girardi et al, 2003).
Mice treated with IgG from APS patients with high levels of
aPL and subjected to a femoral vein pinch model of throm-
bosis, developed larger thrombi and higher soluble TF
activity than controls (Romay-Penabad et al, 2014). The co-
administration of rEV576 (coversin), a recombinant protein
inhibitor of C5 activation, resulted in significantly smaller
thrombi and reduced TF activity (Romay-Penabad et al,
2014). Consistent with this hypothesis, low complement
levels (C3, C5) have been demonstrated in patients with APS
(Oku et al, 2009). In a study of 186 patients with aPL, Breen
et al (2012) found significantly increased levels of fragment
Bb and C3a compared to normal controls. In the RAPS
(Rivaroxaban in Antiphospholipid Syndrome) trial of 111
APS patients; it was demonstrated that APS patients with
previous VTE had significantly increased complement activa-
tion compared to normal controls, which was decreased by
rivaroxaban compared to warfarin therapy (Arachchillage
et al, 2016a).
Catastrophic APS (CAPS) is a rare and potentially fatal
variant of APS characterized by sudden onset of extensive
microvascular thrombosis at multiple sites leading to multi-
organ failure (Cervera et al, 2014). Widespread complement
activation may contribute to CAPS and this is supported by
individual case reports of patients unresponsive to anticoagu-
lation and immunosuppression, but successfully treated with
C5 complement inhibitor eculizumab (Shapira et al, 2012).
As discussed below, complement activation may also be a
central mechanism in aPL-induced pregnancy loss and
intrauterine fetal growth restriction (Salmon et al, 2003).
Complement pathway activation offers several potential tar-
gets for therapeutic complement inhibition, as shown in
Fig 3.
Microvascular thrombosis is one of the major pathological
manifestations of APS and may occur alone or in combina-
tion with large-vessel thrombosis. Kidneys represent the most
important site of microvascular thrombotic/microangiopathic
APS, which is associated with renal failure, thrombotic
microangiopathy and hypertension (Griffiths et al, 2000). In
patients who undergo renal transplantation for APS, the
ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
Review
microvascular thrombotic lesions often recur. In cultured
vascular ECs, IgG antibodies from patients with APS stimu-
lated the mammalian/mechanistic target of rapamycin
(mTOR) through the phosphatidylinositol 3-kinase (PI3K)–
AKT pathway (Canaud et al, 2014) leading to cell prolifera-
tion. It has been shown that mTOR pathway activation plays
a role in endothelial proliferation and intimal hyperplasia in
aPL positive patients, which leads to microthrombosis,
peripheral ischaemia, skin ulcers, diffuse alveolar haemor-
rhage or aPL nephropathy (Manning & Cantley, 2007). The
vascular endothelium of proliferating intrarenal vessels from
patients with APS nephropathy showed evidence of mTOR
complex (mTORC) pathway activation.
Another proposed mechanism of aPL-initiated thrombosis
is through interference with the anticoagulant activity of acti-
vated protein C (APC), resulting in acquired activated pro-
tein C resistance (APCr) (Nojima et al, 2005): aPL inhibition
of the thrombomodulin mediated activation of protein C
(PC), as well as the anticoagulant activity of APC (Malia
et al, 1990), have been observed. Upregulation of the TF
pathway (Adams et al, 2001) by down regulation of its prin-
cipal inhibitor, TF pathway inhibitor (TFPI) (Liestol et al,
2007), may also increase thrombotic risk and studies have
reported the presence of auto-antibodies against TFPI
(aTFPI) in APS patients (Adams et al, 2001). Many in vitro
studies have shown aPL-mediated upregulation of TF expres-
sion on monocytes (Lambrianides et al, 2010) and endothe-
lial cells associated with inflammatory cytokines and
adhesion molecules (Willis et al, 2015); ab2GPI has also been
shown to suppress TFPI-dependent inhibition of the TF
pathway of coagulation (Boles & Mackman, 2010).
Pathogenesis of pregnancy complications in
APS
The presence of aPL probably constitutes the single most
recognisable risk factor in the majority of cases of recurrent
pregnancy loss and late placenta-mediated obstetric compli-
cations. Animal studies have demonstrated that the passive
transfer of aPL promotes fetal loss and placental thrombosis
and also inhibits trophoblast and decidual cell functions
in vitro (Branch et al, 1990). Cross-species investigations
have shown that the exposure of pregnant rats to a purified
IgG fraction from women with APS directly inhibits embryo
growth. Immunopathology of obstetric APS differs from that
of thrombotic APS, especially in the case of recurrent early
miscarriages, where thrombosis is neither a universal nor a
specific feature (Out et al, 1991). Nonetheless, LA may be
associated with extensive placental necrosis, infarction and
thrombosis in women with recurrent pregnancy loss; exten-
sive villous infarction following first trimester miscarriage in
a patient with SLE and positive LA and aCL was first
described by Nayar and Lage (1996).
Annexin V is a cationic protein that normally serves an
anticoagulant function by aggregating on trophoblast
5
Review

Thrombosis
Classical Pathway Pregnancy morbidity

(Activated by antigen/antibody Potent anaphylatoxin

Anaphylatoxins (C3a, C5a) chemotaxis, cell activation
complexes)
aPL ALXN1007
(C5a inhibitor) C5a
C1q Activated C1

C4b2a3b
C4b2a3b Membrane
attack
Lectin pathway complex
C4+C2 C3a C3 C3b C5 C5b
Activated by Mannan C5b-9
Binding lectin (MBL) C3bBb
C6 C7 C8 C9

C3bBb3b
Cell activation
and lysis
Factor B+D
C3 C3b

rEV576(coversin):
Recombinant Eculizumab: Humanized
protein inhibitor of Monoclonal antibody, binds
Alternative pathway
C5 activation to C5, prevents its cleavage
Activated by microbiological membranes, to C5a and C5b
bacterial LPS, immune complexes,
mammalian cell membranes

Fig 3. Complement pathway activation. aPL induced activation of classical pathway leading to thrombosis and pregnancy complications and
potential targets for therapeutic complement inhibition (Adapted from Arachchillage & Hillmen, 2015). The complement cascade is activated by
one of the three pathways. Activation leads to the formation of C3 convertase, resulting in the formation of C5 convertase and membrane attack
complex (MAC). aPL recognize domain I of b2GPI and stabilizes its open configuration on the cell surface. This is followed by binding of com-
plement factor C1q resulting in the activation of the complement system. The formed anaphylatoxins cause cell damage and induce a prothrom-
botic phenotype, leading to both thrombosis and pregnancy failure. Potential therapeutic targets of complement inhibition are also shown. aPL,
antiphospholipid antibodies; LPS, lipopolysaccharide.

membranes and blocking FXa and prothrombin binding.
Thrombosis during the development of the normal materno-
placental circulation may arise via interference with this
function (Rand et al, 1997, 2010a) and women with APS
have disrupted and reduced annexin V binding to the surface
of trophoblastic cells of the intervillous space compared with
controls (Rand et al, 1997). During differentiation to syn-
cytium, trophoblast membrane anionic phospholipids also
bind b2GPI and hence b2GPI-dependent aPL, which may
then lead to defective placentation via complement activa-
tion, inflammatory damage and placental apoptosis (Girardi,
2010).
Studies of animal and human placenta have demonstrated
that complement activation by aPL may play a major role in
the pathogenesis of recurrent pregnancy loss (Salmon et al,
2003). Appropriate complement inhibition is an essential
requirement for normal pregnancy, as evidenced by the find-
ing that deficiency of Crry (a membrane-bound complement
regulatory protein that blocks C3 and C4 activation) leads to
progressive embryonic loss in mice (Xu et al, 2000). It has
been hypothesised that aPL bound to trophoblasts activate
complement via the classical pathway, generating split prod-
ucts that mediate placental injury causing fetal loss and
growth restriction. Passive transfer of IgG from women with
recurrent miscarriage and aPL results in a significant increase
in the frequency of fetal resorption and reduced average
weight of the surviving fetuses, compared to mice treated
with IgG from healthy individuals (Holers et al, 2002). These
effects can be blocked by inhibition of the complement cas-
cade using a C3 convertase inhibitor or by antibodies or pep-
tides that block C5a-C5a receptor interactions (Girardi et al,
2003). Furthermore, mice deficient in C3 are resistant to the
fetal injury induced by aPL (Holers et al, 2002; Girardi et al,
2003) and studies in factor B-deficient mice indicate that the
alternative complement pathway is also required. Inflamma-
tory tissue injury is probably mediated by tumour necrosis

6 ª 2017 John Wiley & Sons Ltd, British Journal of Haematology

 Review

factor (TNF) alpha (TNFa), which increases in murine

decidua after exposure to aPL (Berman et al, 2005) and anti-
body blocking of TNFa reduces fetal resorption (Blank et al,
2003). Finally, the therapeutic effect of heparin has been
shown to operate via inhibition of complement rather than
inhibition of coagulation (Girardi et al, 2004). The PRO-
MISE study (Predictors of pregnancy outcome: biomarkers
In APS and SLE) is a prospective multicentre observational
study which will further evaluate the role of complement in
SLE and aPL-associated pregnancy complications
(NCT00198068).
Animal and human cell culture studies have demonstrated
that binding of aPL (particularly b2GPI-dependent antibod-
ies) to human trophoblasts affects other critical cell func-
tions; inhibition of proliferation and syncitia formation,
decreased production of human chorionic gonadotrophin
and defective secretion of growth factors, as well as inducing
apoptosis (Pierangeli et al, 2008). Moreover aPL may impair
the sequential expression of cell adhesion molecules, such as
integrins and cadherins, in trophoblastic and decidual cells
essential for normal placentation (Di Simone et al, 2002).
Mechanisms for aPL-mediated fetal loss and complications
are summarised in Table II.
Management of thrombosis in antiphos-
pholipid syndrome
Despite the implication of other mechanisms as described
above, anticoagulation rather than immunosuppression
remains the mainstay of management in patients with
thrombotic APS. Two randomised controlled trials have
demonstrated that high-intensity warfarin is not superior to
moderate-intensity warfarin (International Normalized Ratio
[INR] 2
0-3
0) for the prevention of recurrent VTE
(Crowther et al, 2003; Finazzi et al, 2005). The current rec-
ommendation is that patients with APS and otherwise
unprecipitated VTE should remain on anticoagulants indefi-
nitely with a target INR of 2
5, which reduces recurrent VTE
by 80–90% compared to no treatment (Ruiz-Irastorza et al,
2011; Danowski et al, 2013). Indefinite anticoagulation for
APS patients is supported by evidence that APS patients
carry a higher risk of recurrent thrombosis compared to
aPL-negative subjects and that the thrombotic risk may
increase with time (Ruiz-Irastorza et al, 2002). However, in a
systematic review, the strength of this association was uncer-
tain because the available evidence was of very low quality
(Garcia et al, 2013). Thrombosis after a clear precipitant

Table II. Mechanisms for aPL-mediated fetal loss or complications

Mechanism Supporting evidence from studies in humans or animals/comments

Intraplacental thrombosis
Inflammation
Interference with Annexin V function
Inhibition of syncytium-trophoblast
differentiation and defective
placentation/placental apoptosis
Complement activation
Animal studies have demonstrated that the passive transfer of aPL promotes fetal loss and placental
thrombosis and also inhibits trophoblast and decidual cell functions in vitro (Branch et al, 1990).
Placental thrombosis and infarction shown in APS patients with intra-uterine fetal death (Out et al,
1991; Nayar & Lage, 1996)
aPL binding to monocytes, endothelial cells, platelets and plasma components of the coagulation
cascade (Zhang & Mccrae, 2005) may lead to placental thrombosis.
aPL might induce a procoagulant state at the placental level by disrupting the anticoagulant annexin
A5 shield on trophoblast and endothelial cell monolayers (Rand et al, 1997)
b2GPI-dependent aPL are able to react with human stromal decidual cells in vitro, inducing a
proinflammatory phenotype(Zhang & Mccrae, 2005)
Thrombosis during the development of the normal materno-placental circulation may arise via
interference with function of Annexin V (Rand et al, 1997, 2010a) and women with APS have
diminished annexin V binding to the surface of trophoblastic cells of the intervillous space
compared with controls (Rand et al, 1997).
aPL (particularly b2GPI-dependent antibodies) bind to human trophoblasts and affect several cell
functions (Girardi et al, 2003), inducing cell injury and apoptosis, inhibition of proliferation and
syncitia formation, decreased production of human chorionic gonadotrophin, defective secretion of
growth factors and impaired invasiveness which lead to defective placentation.
Passive transfer of IgG from women with recurrent miscarriage and aPL results in a significant
increase in the frequency of fetal resorption and IUGR, compared to mice treated with IgG from
healthy individuals [(Holers et al, 2002). These effects can be blocked by inhibition of the
complement cascade using a C3 convertase inhibitor or by antibodies or peptides that block C5a-
C5a receptor interactions (Girardi et al, 2003).
Mice deficient in complement C3 are resistant to fetal injury induced by aPL (Holers et al, 2002;
Girardi et al, 2003).
Heparin prevents obstetric complications caused by aPL, because it blocks complement activation
rather than through its antithrombotic properties (Girardi et al, 2004).

aPL, antiphospholipid antibodies; APS, antiphosphlipid syndrome; IUGR, intrauterine growth restriction; b2GPI, b2glycoprotein-I.

ª 2017 John Wiley & Sons Ltd, British Journal of Haematology 7

Review
should not prompt testing for APS and requires only
3 months of anticoagulation (Keeling et al, 2012).
With regards to the optimal intensity of anticoagulation
following arterial thrombosis, an earlier prospective cohort
study, the Antiphospholipid Antibodies and Stroke Study
(APASS), found no benefit of low intensity warfarin anti-
coagulation (target INR 1
4–2
8) over aspirin (325 mg/day)
in stroke prevention (Levine et al, 2004). However, the
study had important limitations, such as low target INR
and aPL testing being performed only on entry to the
study, raising the possibility that some participants may
have had transient antibody positivity. Other studies
demonstrated that moderate-intensity warfarin (INR 2
0–
3
0) is effective for arterial thrombosis and APS, although
patients with arterial thrombosis were poorly represented
in these trials (only, 24% and 32% respectively) (Crowther
et al, 2003; Finazzi et al, 2005). Ruiz-Irastorza et al (2007)
recommended, following a systematic review of cohort
studies, that APS with arterial thrombosis and/or recurrent
venous events should be treated with warfarin at an INR
>3
0. Although the 13th International Congress on
Antiphospholipid Antibodies task force also recommended
an INR >3
0 or combined platelet inhibitor-anticoagulant
(INR 2
0–3
0) therapy for arterial thrombosis (Ruiz-Iras-
torza et al, 2011), this was a non-graded recommendation
due to lack of consensus within the panel members. Stan-
dard practice currently is for a target INR of 2
5, with
escalation to a higher target INR should thrombosis recur
(Keeling et al, 2012).
The narrow therapeutic range and multiple interactions of
warfarin are further complicated in APS by the variable
responsiveness of thromboplastins to LA, leading to mislead-
ing INR results. However, monitoring of INR is not a major
issue in the majority of patients with APS and the problem
is limited to specific thromboplastins (Tripodi et al, 2001).
Direct acting oral anticoagulants
Direct acting oral anticoagulants (DOACs) are fixed dose
oral anticoagulants with predictable anticoagulant effect and,
consequently, no need for routine monitoring. DOACs are
established as therapeutic alternatives to vitamin K antago-
nists (VKAs) for treatment and secondary prevention of VTE
in patients without APS. Although aPL are reported in
approximately 10% of patients with VTE (Andreoli et al,
2013), phase III clinical trials have not compared warfarin
versus DOAC for this group and experience is limited to case
reports. A total of 96 APS patients are reported to be treated
with DOACs [82/96 (85
5%) rivaroxaban, 13/96 (13
5%)
dabigatran and 1/96 (1%) apixaban] (Bachmeyer & Elalamy,
2014; Schaefer et al, 2014; Win & Rodgers, 2014; Noel et al,
2015; Sciascia et al, 2015; Son et al, 2015; Betancur et al,
2016; Signorelli et al, 2016). Only 8/96 (8
3%) of the patients
received a DOAC as acute treatment for VTE. 17 patients
had recurrent thrombosis. However, those who had recurrent
8 ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
arterial thrombosis had a severe thrombotic phenotype at the
time of starting a DOAC and standard risk APS patients who
were on warfarin with target INR of 2
0–3
0 had no recur-
rent events. Only two patients [2/96 (2
1%)] had bleeding
events.
Rivaroxaban has been shown to effectively reduce throm-
bin generation in plasma from patients with thrombotic APS
compared to warfarin in a recently published randomised
clinical trial (Cohen et al, 2016), but there are no data from
intervention trials designed to assess clinical endpoints. Sev-
eral other clinical trials assessing the use of DOAC is throm-
botic APS are still recruiting participants (NCT02157272,
NCT02295475, NCT02116036). However, given their general
efficacy, DOAC could be considered as an alternative antico-
agulant in patients with APS and VTE that are usually trea-
ted with standard-intensity warfarin when there is known
VKA allergy or poor anticoagulant control. DOACs have not
been studied in patients with arterial thrombosis even with-
out APS and the comparison has been always with standard
intensity warfarin anticoagulation. Therefore, DOACs are not
recommended in APS patients with arterial thrombosis or
those with recurrent VTE whilst achieving therapeutic antico-
agulation with warfarin.
For the small proportion of patients with APS who
develop recurrent thrombosis despite apparently adequate
anticoagulation, an increase in warfarin intensity is recom-
mended (i.e: target INR of 3
5). There are limited therapeutic
options for patients who have recurrent thrombosis despite
high-intensity warfarin. These include addition of an antipla-
telet agent or low molecular weight heparin (LMWH),
including high-intensity LMWH (maintaining peak anti Xa
levels 1
6–2
0 iu/ml for once daily dosing and peak 0
8–1
0
iu/ml for twice daily dosing) or combined factor Xa and fac-
tor IIa inhibitors (Arachchillage et al, 2016b). When antico-
agulation has failed, other available therapeutic options
include combining anticoagulation with immunosuppression
and/or immunomodulation with modalities including ritux-
imab, hydroxychloroquine, statins rituximab complement
inhibitors and mTOR inhibitors, such as sirolimus.
Hydroxychloroquine
Hydroxychloroquine (HCQ) is a well-established treatment
for patients with SLE and rheumatoid arthritis due to its
anti-inflammatory effects; inhibiting cytosolic phospholipase
A2 and reducing the release of the cytokines interleukin (IL)
6 and TNF (Sperber et al, 1993). It is currently recom-
mended as a baseline therapy in all patients with SLE who
have no contraindications (Ruiz-Irastorza et al, 2010). HCQ
also inhibits platelet aggregation and arachidonic acid release,
reducing thrombus size in mice models of APS (Espinola
et al, 2002; Rand et al, 2010b) and protects the Annexin V
anticoagulant shield from disruption by aPL (Rand et al,
2010a). Its antithrombotic activity is demonstrated by its effi-
cacy as thromboprophylaxis after hip surgery (Johansson
 Review

et al, 1981) and in patients with SLE, without increased Complement inhibition
bleeding (Schmidt-Tanguy et al, 2013). Recent APS consensus
The experimental evidence discussed above has led to specu-
guidelines support its use as an adjuvant to anticoagulation
lation that inhibition of complement may be a useful thera-
in patients with recurrent thrombosis despite anticoagulation
peutic strategy in APS, although only preliminary and
(Ruiz-Irastorza et al, 2011). A phase III multicentre trial
anecdotal data are available to date. A phase II clinical trial
exploring the effect of HCQ as primary thrombosis prophy-
evaluating the use of eculizumab to enable renal transplanta-
laxis in individuals with persistently positive antiphospholipid
tion and prevent post-transplant thrombotic microangiopa-
antibodies (NCT01784523) has been now completed and
thy (TMA) in patients with a history of CAPS
findings are awaited.
(NCT01029587) is ongoing, but not recruiting participants.
Preliminary data of this study from 80 patients showed that
Statins eculizumab is effective in reducing the incidence of acute
antibody-mediated rejection in sensitized deceased donor
Statins inhibit the enzyme 3-hydroxy-3-methyl-glutaryl-
kidney transplant recipients (KTR). Patient and graft survival
coenzyme A (HMG-CoA) reductase (HMGCR), which has a
and kidney function at 1 year were similar to those expected
central role in hepatic cholesterol production, but also have
for non-sensitized KTR (Glotz et al, 2015). Another phase II
pleiotropic effects including anti-inflammatory and
multicentre clinical trial evaluating the safety and tolerability
antithrombotic actions on EC and monocytes (Ferrara et al,
of intravenous ALXN1007 (C5a inhibitor) in persistently
2003). Furthermore, there is evidence they increase fibrinol-
aPL-positive patients with at least one of the non-criteria
ysis and decrease tissue factor mRNA expression; opposite
manifestations of APS is underway NCT02128269.
effects to aPL (Ferrara et al, 2004). These observations and
the demonstrated VTE reduction in patients receiving sta-
tins (Ridker, 2009) suggest a possible benefit from their use Sirolimus
in APS. In a prospective open-label pilot study of fluvas-
Sirolimus is an mTOR inhibitor that is currently used to pre-
tatin in aPL positive patients, Erkan et al (2014a) demon-
vent reactive arterial stenosis after coronary stenting. A
strated that fluvastatin can reduce pro-inflammatory and
cohort of patients with APS nephropathy who required
pro-thrombotic biomarkers, such as IL6, IL1b, vascular
transplantation and were receiving sirolimus had no recur-
endothelial growth factor, TNFa and interferon-a. Based on
rence of vascular lesions and had decreased vascular prolifer-
available evidence, the 14th International Congress on
ation on biopsy as compared to APS patients not receiving
Antiphospholipid Antibodies Task Force Report on APS
sirolimus (Canaud et al, 2014). Graft survival at 144 months
Treatment Trends stated that statins cannot be recom-
was 7/10 (70%) versus 3/27 (11%) in the two groups. Fur-
mended in APS patients in the absence of hyperlipidaemia,
ther larger studies are required to establish the routine use of
but may be a useful treatment adjunct in APS patients with
mTOR inhibitors in APS patients.
recurrent thrombosis despite adequate anticoagulation
(Erkan et al, 2014b).
Potential future therapeutic options
Rituximab TIFI is a 20-amino acid peptide from human cytomegalo-
virus, which shares similarities with the PL-binding site in
Rituximab appears to be an effective treatment for thrombo-
the b2GPI molecule, DV. In vitro evidence suggests that TIFI
cytopenia and haemolytic anaemia associated with aPL (Erre
inhibits the binding of labelled b2GPI to human ECs and
et al, 2008) and may improve some other manifestations,
mouse monocytes (Ostertag et al, 2006). In a mouse model
such as skin ulcers (Erkan et al, 2013). Rituximab has been
of APS, infusion of TIFI reduced the binding of fluores-
used for the treatment of difficult cases, such as refractory
ceinated b2GPI to ECs and reduced thrombosis size after aPL
thrombocytopenia or other non-criteria aPL manifestations,
infusion (de la Torre et al, 2012). A dimeric peptide of b2-
CAPS, and recurrent VTE, in over 50 case reports. In a
glycoprotein-DI (DI dimer) has a similar effect (Agostinis
review by Kumar and Roubey (2010), it was reported that
et al, 2014). These peptides are not yet in clinical trials but
rituximab had a beneficial clinical effect in 19 of 21 pub-
may offer a new paradigm for APS treatment in the future.
lished cases and aPL levels were significantly decreased in ten
of 12 cases. Review of the CAPS registry of 20 patients trea-
ted with rituximab reported a recovery rate of 75% of acute Management of CAPS
episodes in combination with multiple treatment strategies,
Anticoagulation, intravenous immunoglobulin (IVIG),
including anticoagulation, steroids, plasma exchange and
plasma exchange, immunosuppressive therapy, prostacyclin,
cyclophosphamide (Berman et al, 2013); consequently, the
fibrinolytics and defibrotide have all been used in the man-
responses cannot be clearly attributed to rituximab alone.
agement of CAPS. Case reports described above suggest ecu-
Furthermore, there was no consistency in the reduction in
lizumab may be effective in CAPS unresponsive to other
aPL level in these patients.

ª 2017 John Wiley & Sons Ltd, British Journal of Haematology 9

Review
treatments (Shapira et al, 2012) and in preventing relapse
after kidney transplantation. There are reported cases of
rituximab use in patients with CAPS with variable responses
(Erre et al, 2008). Espinosa et al (2011) reviewed 9 such
patients, two of who died; but notably, in three of the sur-
viving patients’ tests for aPL became negative after rituximab
treatment.
Management of asymptomatic carriers of aPL
Another unanswered question is whether primary thrombo-
prophylaxis is indicated in subjects with aPL and how risk of
a first thrombosis can be stratified in order to personalise
treatment. A prospective evaluation of the incidence and risk
factors for a first vascular event in 258 asymptomatic indi-
viduals with aPL determined that the annual incidence rate
was 1
86% compared to 0
1% in the general population with
a median follow-up of 35 months (range 1-48) (Ruffatti
et al, 2011). Hypertension and the presence of LA were iden-
tified as independent risk factors for development of throm-
bosis (Ruffatti et al, 2011). In a study of 104 subjects with
triple positivity, there were 25 first thrombotic events (5
3%
per year) with a cumulative incidence of 37
1% (95% CI:
19
9%-54
3%) after 10 years. Aspirin did not significantly
reduce the incidence of thromboembolic events (Pengo et al,
2011). The Antiphospholipid Antibody Acetylsalicyclic Acid
(APLASA) study randomised individuals with asymptomatic,
persistently positive aPL to receive 81 mg of aspirin or pla-
cebo daily (Erkan et al, 2007). There was no significant dif-
ference in outcome between the two arms. On current
evidence, thromboprophylaxis with aspirin and/or VKA is
not recommended for asymptomatic, aPL positive individu-
als. Whether subjects who are triple aPL-positive should be
treated differently remains to be established.
Treatment of obstetric APS
Heparin and low dose aspirin (LDA) is the treatment of
choice for recurrent pregnancy loss associated with APS. This
is based on several important studies (Kutteh, 1996; Rai et al,
1997). In a meta-analysis of data from five trials that ran-
domly assigned patients to either heparin and aspirin or
aspirin alone for the management of APS-related pregnancies
(Mak et al, 2010), the overall live birth rates in 334 patients
were 74
27% and 55
85% respectively (relative risk 1
301;
95% CI 1
040, 1
629). The American College of Chest Physi-
cians (ACCP) guidelines (Bates et al, 2012) recommend
treating women with obstetric APS who meet the revised
Sapporo criteria with heparin and LDA in the antepartum
period as soon as pregnancy is confirmed. LMWH is gener-
ally favoured due to a lower incidence of heparin-induced
thrombocytopenia and low risk of osteopenia compared to
unfractionated heparin. The key observation made by Girardi
et al (2004), that heparin can inhibit complement-mediated
apoptosis, provides a possible explanation for its efficacy
10
independent of its anticoagulant activity. Heparin may also
act by inhibiting aPL binding to trophoblastic cell mem-
branes, modulating trophoblast apoptosis, promoting tro-
phoblast cell invasiveness, and reducing complement
activation with the ensuing inflammatory response at the
decidual-placental interface (Franklin & Kutteh, 2003).
Women with obstetric APS but no prior history of VTE,
post-partum thromboprophylaxis should be considered/of-
fered for 6 weeks following delivery based on risk assessment.
However, there is variation in guidelines as well as clinical
practice regarding this. The Nimes Obstetricians and Haema-
tologists Antiphospholipid Syndrome (NOH-APS) observa-
tional study reported that the annual rates of DVT (1
46%;
range 1
15–1
82%), pulmonary embolism (0
43%; range
0
26–0
66%), superficial vein thrombosis (0
44%; range 0
28–
0
68%), and cerebrovascular events (0
32%; range 0
18–
0
53%) were significantly higher in women with pure obstet-
ric APS compared with aPL-negative women with obstetric
morbidity, despite LDA primary prophylaxis (Gris et al,
2012). British Committee for Standards in Haematology
(Keeling et al, 2012) and Royal College of Obstetricians and
Gynaecologists guidelines are in keeping with this observa-
tion. The RCOG Green-top Guideline (https://www.rcog.org.
uk/globalassets/documents/guidelines/gtg-37a.pdf), states
‘Persistent antiphospholipid antibodies (LA and/or anticardi-
olipin and/or anti-b2-GPI 1 antibodies) in women without
previous VTE should be considered as a risk factor for
thrombosis such that if she has other risk factors she may be
considered for antenatal or postnatal thromboprophylaxis’
(either 10 day or 6 weeks based on risk assessment). If VTE
develops during pregnancy, treatment with therapeutic doses
of LMWH should be employed during the remainder of the
pregnancy and for at least 6 weeks postnatally and until at
least 3 months of treatment has been given in total (https://
www.rcog.org.uk/globalassets/documents/guidelines/gtg-37b.
pdf). However, women with thrombosis during pregnancy
and positive aPL should be reassessed after pregnancy in case
long-term anticoagulation is indicated.
With standard treatment, approximately 70% of pregnant
women with APS have successful pregnancy outcome (Bram-
ham et al, 2010). There are limited therapeutic options and
no guidelines for those who do not respond to heparin and
LDA. Addition of low-dose prednisolone to standard treat-
ment in the first-trimester improved the live birth rate in
refractory aPL-related first trimester pregnancy loss (Bram-
ham et al, 2011): nearly two-thirds of pregnancies (61%)
resulted in live births, of which 8 (57%) were uncomplicated
term pregnancies. However, the frequency of some complica-
tions remained elevated, mainly preterm delivery (21%).
Data on the usefulness of IVIG in obstetric APS are conflict-
ing (Parke et al, 1989; Branch et al, 2000).
In a mouse model of obstetric APS HCQ prevented fetal
death and the placental metabolic changes as measured by
proton magnetic resonance spectroscopy (Bertolaccini et al,
2016). The same study showed that HCQ prevented
ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
 Review

complement activation in vivo and in vitro. Complement C5a
levels in serum samples from APS patients and APS-mice
were lower after treatment with HCQ while the antibodies
titres remained unchanged. HCQ prevented not only placen-
tal insufficiency but also abnormal fetal brain development
in APS (Bertolaccini et al, 2016). A European multicentre
retrospective study of 30 patients with APS and 35 pregnan-
cies showed a better outcome of pregnancies that were trea-
ted by the addition of HCQ when compared with previous
pregnancies under the conventional treatment (Mekinian
et al, 2015). Sciascia et al (2016) reported HCQ-treatment
was associated with a higher rate of live births (67% vs. 57%;
P = 0
05) and a lower prevalence of aPL–related pregnancy
morbidity (47% vs. 63%; P = 0
004).
complications of pregnancy. Warfarin, heparin and/or anti-
platelet drugs are still the standard of care for APS-thrombo-
sis and although attractive, DOAC can, at present, only be
considered as an alternative in patients with APS and VTE
that are usually treated with standard-intensity warfarin
when there is known VKA allergy or poor anticoagulant con-
trol. The realisation that additional pathways are involved in
the pathogenesis of APS has significant implications for treat-
ment. Agents acting outside the coagulation system, such as
HCQ for pregnancy complications and sirolimus as an inhi-
bitor of the mTOR pathway are now under evaluation and
represent a potential radical change in thinking for haematol-
ogists.

Author contribution
Conclusion
DRJ Arachchillage performed the literature search and wrote
Despite the clear association between aPL and the throm- the first draft. M Laffan critically reviewed the manuscript
botic and obstetric manifestations of APS, the exact mecha- and both authors approved the final manuscript.
nisms by which aPL cause these problems is yet to be fully
established. However, the activation of complement and
Conflict of interest
endothelial cells by DI-specific anti-b2GPI antibodies has
emerged as an important component. Incorporation of DI- The authors state that they have no relevant conflict of inter-
specific anti-b2GPI antibodies into diagnostic panels may est.
allow better identification of those at high risk for clinical
events. Related but distinct pathways also link aPL to the

References
Abreu, M.M., Danowski, A., Wahl, D.G., Amigo,
M.C., Tektonidou, M., Pacheco, M.S., Fleming,
N., Domingues, V., Sciascia, S., Lyra, J.O., Petri,
M., Khamashta, M. & Levy, R.A. (2015) The rel-
evance of “non-criteria” clinical manifestations
of antiphospholipid syndrome:14th International
Congress on Antiphospholipid Antibodies Tech-
nical Task Force Report on Antiphospholipid
Syndrome Clinical Features. Autoimmunity
Reviews, 14, 401–414.
Adams, M.J., Donohoe, S., Mackie, I.J. & Machin,
S.J. (2001) Anti-tissue factor pathway inhibitor
activity in patients with primary antiphospho-
lipid syndrome. British Journal of Haematology,
114, 375–379.
Agar, C., van Os, G.M., Morgelin, M., Sprenger,
R.R., Marquart, J.A., Urbanus, R.T., Derksen,
R.H., Meijers, J.C. & de Groot, P.G (2010)
Beta2-glycoprotein I can exist in 2 conforma-
tions: implications for our understanding of the
antiphospholipid syndrome. Blood, 116, 1336–
1343.
Agostinis, C., Durigutto, P., Sblattero, D., Borghi,
M.O., Grossi, C., Guida, F., Bulla, R., Macor, P.,
Pregnolato, F., Meroni, P.L. & Tedesco, F (2014)
A non-complement-fixing antibody to beta2 gly-
coprotein I as a novel therapy for antiphospho-
lipid syndrome. Blood, 123, 3478–3487.
Andreoli, L., Chighizola, C.B., Banzato, A., Pons-
Estel, G.J., Ramire de, J.G. & Erkan, D. (2013)
Estimated frequency of antiphospholipid anti-
bodies in patients with pregnancy morbidity,
stroke, myocardial infarction, and deep vein
thrombosis: a critical review of the literature.
Arthritis Care & Research, 65, 1869–1873.
Arachchillage, D.R.J. & Hillmen, P. (2015) Parox-
ysmal nocturnal haemoglobinuria in pregnancy.
In: Disorders of Thrombosis and Haemostasis in
Pregnancy (ed. by Cohen, H & O’Brien, P). pp.
327–342. 2nd edn. Springer, London.
Arachchillage, D.R., Efthymiou, M., Mackie, I.J.,
Lawrie, A.S., Machin, S.J. & Cohen, H. (2014)
Anti-protein C antibodies are associated with
resistance to endogenous protein C activation
and a severe thrombotic phenotype in antiphos-
pholipid syndrome. Journal of Thrombosis and
Haemostasis, 12, 1801–1809.
Arachchillage, D.R., Mackie, I.J., Efthymiou, M.,
Chitolie, A., Hunt, B.J., Isenberg, D.A.,
Khamashta, M., Machin, S.J. & Cohen, H.
(2016a) Rivaroxaban limits complement activa-
tion compared with warfarin in antiphospholipid
syndrome patients with venous thromboem-
bolism. Journal of Thrombosis and Haemostasis,
14, 2177–2186.
Arachchillage, D.R., Besser, M., Maclean, R.,
Baglin, T. & van Veen, J.J. (2016b) Combined
factor IIa and Xa inhibitor therapy for thrombo-
sis whilst on therapeutic anticoagulant. Throm-
bosis Research, 143, 137–140.
Arad, A., Proulle, V., Furie, R.A., Furie, B.C. &
Furie, B. (2011) beta(2)-Glycoprotein-1
autoantibodies from patients with antiphospho-
lipid syndrome are sufficient to potentiate arte-
rial thrombus formation in a mouse model.
Blood, 117, 3453–3459.
Artenjak, A., Locatelli, I., Brelih, H., Simonic,
D.M., Ulcova-Gallova, Z., Swadzba, J., Musial,
J., Iwaniec, T., Stojanovich, L., Conti, F., Vale-
sini, G., Avcin, T., Cohen Tervaert, J.W., Shoen-
feld, Y., Blank, M., Ambrozic, A., Sodin-Semrl,
S., Bozic, B. & Cucnik, S. (2015) Immunoreac-
tivity and avidity of IgG anti-beta2-glycoprotein
I antibodies from patients with autoimmune
diseases to different peptide clusters of beta2-
glycoprotein I. Immunologic Research, 61, 35–44.
Bachmeyer, C. & Elalamy, I. (2014) Rivaroxaban
as an effective treatment for recurrent superficial
thrombophlebitis related to primary antiphos-
pholipid syndrome. Clinical and Experimental
Dermatology, 39, 840–841.
Banzato, A., Pozzi, N., Frasson, R., De Filippis, V.,
Ruffatti, A., Bison, E., Padayattil, S.J., Denas, G.
& Pengo, V. (2011) Antibodies to Domain I of
beta(2)Glycoprotein I are in close relation to
patients risk categories in Antiphospholipid Syn-
drome (APS). Thrombosis Research, 128, 583–
586.
Bas de Laat, H., Derksen, R.H. & de Groot, P.G.
(2004) beta2-glycoprotein I, the playmaker of
the antiphospholipid syndrome. Clinical
Immunology, 112, 161–168.
Bates, S.M., Greer, I.A., Middeldorp, S., Veenstra,
D.L., Prabulos, A.M. & Vandvik, P.O. (2012)

ª 2017 John Wiley & Sons Ltd, British Journal of Haematology 11

Review
VTE, thrombophilia, antithrombotic therapy,
and pregnancy: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American
College of Chest Physicians Evidence-Based
Clinical Practice Guidelines. Chest, 141, e691S–
e736S.
Berman, J., Girardi, G. & Salmon, J.E. (2005)
TNF-alpha is a critical effector and a target for
therapy in antiphospholipid antibody-induced
pregnancy loss. Journal of Immunology, 174,
485–490.
Berman, H., Rodriguez-Pinto, I., Cervera, R.,
Morel, N., Costedoat-Chalumeau, N., Erkan, D.,
Shoenfeld, Y. & Espinosa, G. (2013) Rituximab
use in the catastrophic antiphospholipid syn-
drome: descriptive analysis of the CAPS registry
patients receiving rituximab. Autoimmunity
Reviews, 12, 1085–1090.
Bertolaccini, M.L., Contento, G., Lennen, R.,
Sanna, G., Blower, P.J., Ma, M.T., Sunassee, K.
& Girardi, G. (2016) Complement inhibition by
hydroxychloroquine prevents placental and fetal
brain abnormalities in antiphospholipid syn-
drome. Journal of Autoimmunity, 75, 30–38.
Betancur, J.F., Bonilla-Abadia, F., Hormaza, A.A.,
Jaramillo, F.J., Canas, C.A. & Tobon, G.J. (2016)
Direct oral anticoagulants in antiphospholipid
syndrome: a real life case series. Lupus, 25, 658–
662.
Blank, M., Krause, I., Wildbaum, G., Karin, N. &
Shoenfeld, Y. (2003) TNFalpha DNA vaccina-
tion prevents clinical manifestations of experi-
mental antiphospholipid syndrome. Lupus, 12,
546–549.
Boles, J. & Mackman, N. (2010) Role of tissue fac-
tor in thrombosis in antiphospholipid antibody
syndrome. Lupus, 19, 370–378.
Bowie, E.J., Thompson, J.H. Jr, Pascuzzi, C.A. &
Owen, C.A. Jr (1963) Thrombosis in systemic
lupus erythematosus despite circulating antico-
agulants. Journal of Laboratory and Clinical Med-
icine, 62, 416–430.
Bramham, K., Hunt, B.J., Germain, S., Calatayud,
I., Khamashta, M., Bewley, S. & Nelson-Piercy,
C. (2010) Pregnancy outcome in different clini-
cal phenotypes of antiphospholipid syndrome.
Lupus, 19, 58–64.
Bramham, K., Thomas, M., Nelson-Piercy, C.,
Khamashta, M. & Hunt, B.J. (2011) First-trime-
ster low-dose prednisolone in refractory
antiphospholipid antibody-related pregnancy
loss. Blood, 117, 6948–6951.
Branch, D.W., Dudley, D.J., Mitchell, M.D.,
Creighton, K.A., Abbott, T.M., Hammond, E.H.
& Daynes, R.A. (1990) Immunoglobulin G frac-
tions from patients with antiphospholipid anti-
bodies cause fetal death in BALB/c mice: a
model for autoimmune fetal loss. American
Journal of Obstetrics and Gynecology, 163, 210–
216.
Branch, D.W., Peaceman, A.M., Druzin, M., Silver,
R.K., El-Sayed, Y., Silver, R.M., Esplin, M.S.,
Spinnato, J. & Harger, J. (2000) A multicenter,
placebo-controlled pilot study of intravenous
immune globulin treatment of antiphospholipid
12
syndrome during pregnancy. The Pregnancy
Loss Study Group. American Journal of Obstet-
rics and Gynecology, 182, 122–127.
Breen, K.A., Seed, P., Parmar, K., Moore, G.W.,
Stuart-Smith, S.E. & Hunt, B.J. (2012) Comple-
ment activation in patients with isolated
antiphospholipid antibodies or primary
antiphospholipid syndrome. Thrombosis and
Haemostasis, 107, 423–429.
Canaud, G., Bienaime, F., Tabarin, F., Bataillon,
G., Seilhean, D., Noel, L.H., Dragon-Durey,
M.A., Snanoudj, R., Friedlander, G., Halbwachs-
Mecarelli, L., Legendre, C. & Terzi, F. (2014)
Inhibition of the mTORC pathway in the
antiphospholipid syndrome. The New England
Journal of Medicine, 371, 303–312.
Cervera, R., Rodriguez-Pinto, I., Colafrancesco, S.,
Conti, F., Valesini, G., Rosario, C., Agmon-
Levin, N., Shoenfeld, Y., Ferrao, C., Faria, R.,
Vasconcelos, C., Signorelli, F. & Espinosa, G.
(2014) 14th International Congress on
Antiphospholipid Antibodies Task Force Report
on Catastrophic Antiphospholipid Syndrome.
Autoimmunity Reviews, 13, 699–707.
Cohen, H., Hunt, B.J., Efthymiou, M., Arachchil-
lage, D.R., Mackie, I.J., Clawson, S., Sylvestre,
Y., Machin, S.J., Bertolaccini, M.L., Ruiz-Castel-
lano, M., Muirhead, N., Dore, C.J., Khamashta,
M. & Isenberg, D.A. (2016) Rivaroxaban versus
warfarin to treat patients with thrombotic
antiphospholipid syndrome, with or without
systemic lupus erythematosus (RAPS): a ran-
domised, controlled, open-label, phase 2/3, non-
inferiority trial. Lancet Haematology, 3, e426–
e436.
Conley, C. & Hartmann, R.C. (1952) A hemor-
rhagic disorder caused by circulating anticoagu-
lant in patients with disseminated lupus
erythematosus. Journal of Clinical Investigation,
31, 2.
Crowther, M.A., Ginsberg, J.S., Julian, J., Denburg,
J., Hirsh, J., Douketis, J., Laskin, C., Fortin, P.,
Anderson, D., Kearon, C., Clarke, A., Geerts,
W., Forgie, M., Green, D., Costantini, L.,
Yacura, W., Wilson, S., Gent, M. & Kovacs, M.J.
(2003) A comparison of two intensities of war-
farin for the prevention of recurrent thrombosis
in patients with the antiphospholipid antibody
syndrome. The New England Journal of Medicine,
349, 1133–1138.
Danowski, A., Rego, J., Kakehasi, A.M., Funke, A.,
Carvalho, J.F., Lima, I.V., Souza, A.W. & Levy,
R.A. (2013) Guidelines for the treatment of
antiphospholipid syndrome. Revista Brasileira de
Reumatologia, 53, 184–192.
Di Simone, N., Castellani, R., Caliandro, D. & Car-
uso, A. (2002) Antiphospholid antibodies regu-
late the expression of trophoblast cell adhesion
molecules. Fertility and Sterility, 77, 805–811.
Erkan, D., Harrison, M.J., Levy, R., Peterson, M.,
Petri, M., Sammaritano, L., Unalp-Arida, A.,
Vilela, V., Yazici, Y. & Lockshin, M.D. (2007)
Aspirin for primary thrombosis prevention in
the antiphospholipid syndrome: a randomized,
double-blind, placebo-controlled trial in
ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
asymptomatic antiphospholipid antibody-posi-
tive individuals. Arthritis and Rheumatism, 56,
2382–2391.
Erkan, D., Vega, J., Ramon, G., Kozora, E. & Lock-
shin, M.D. (2013) A pilot open-label phase II
trial of rituximab for non-criteria manifestations
of antiphospholipid syndrome. Arthritis and
Rheumatism, 65, 464–471.
Erkan, D., Willis, R., Murthy, V.L., Basra, G.,
Vega, J., Ruiz-Limon, P., Carrera, A.L., Papa-
lardo, E., Martinez-Martinez, L.A., Gonzalez,
E.B. & Pierangeli, S.S. (2014a) A prospective
open-label pilot study of fluvastatin on proin-
flammatory and prothrombotic biomarkers in
antiphospholipid antibody positive patients.
Annals of the Rheumatic Diseases, 73, 1176–1180.
Erkan, D., Aguiar, C.L., Andrade, D., Cohen, H.,
Cuadrado, M.J., Danowski, A., Levy, R.A., Ortel,
T.L., Rahman, A., Salmon, J.E., Tektonidou,
M.G., Willis, R. & Lockshin, M.D. (2014b) 14th
International Congress on Antiphospholipid
Antibodies: task force report on antiphospho-
lipid syndrome treatment trends. Autoimmunity
Reviews, 13, 685–696.
Erre, G.L., Pardini, S., Faedda, R. & Passiu, G.
(2008) Effect of rituximab on clinical and labo-
ratory features of antiphospholipid syndrome: a
case report and a review of literature. Lupus, 17,
50–55.
Espinola, R.G., Pierangeli, S.S., Gharavi, A.E. &
Harris, E.N. (2002) Hydroxychloroquine
reverses platelet activation induced by human
IgG antiphospholipid antibodies. Thrombosis
and Haemostasis, 87, 518–522.
Espinosa, G., Berman, H. & Cervera, R. (2011)
Management of refractory cases of catastrophic
antiphospholipid syndrome. Autoimmunity
Reviews, 10, 664–668.
Ferrara, D.E., Liu, X., Espinola, R.G., Meroni, P.L.,
Abukhalaf, I., Harris, E.N. & Pierangeli, S.S.
(2003) Inhibition of the thrombogenic and
inflammatory properties of antiphospholipid
antibodies by fluvastatin in an in vivo animal
model. Arthritis and Rheumatism, 48, 3272–3279.
Ferrara, D.E., Swerlick, R., Casper, K., Meroni,
P.L., Vega-Ostertag, M.E., Harris, E.N. & Pier-
angeli, S.S. (2004) Fluvastatin inhibits up-regula-
tion of tissue factor expression by
antiphospholipid antibodies on endothelial cells.
Journal of Thrombosis and Haemostasis, 2, 1558–
1563.
Finazzi, G., Marchioli, R., Brancaccio, V., Schinco,
P., Wisloff, F., Musial, J., Baudo, F., Berrettini,
M., Testa, S., D’Angelo, A., Tognoni, G. & Bar-
bui, T. (2005) A randomized clinical trial of
high-intensity warfarin vs. conventional
antithrombotic therapy for the prevention of
recurrent thrombosis in patients with the
antiphospholipid syndrome (WAPS). Journal of
Thrombosis and Haemostasis, 3, 848–853.
Franklin, R.D. & Kutteh, W.H. (2003) Effects of
unfractionated and low molecular weight hep-
arin on antiphospholipid antibody binding
in vitro. Obstetrics and Gynecology, 101, 455–
462.

Galli, M., Comfurius, P., Maassen, C., Hemker,
H.C., de Baets, M.H., van Breda-Vriesman, P.J.,
Barbui, T., Zwaal, R.F. & Bevers, E.M. (1990)
Anticardiolipin antibodies (ACA) directed not
to cardiolipin but to a plasma protein cofactor.
Lancet, 335, 1544–1547.
Galli, M., Luciani, D., Bertolini, G. & Barbui, T.
(2003) Lupus anticoagulants are stronger risk
factors for thrombosis than anticardiolipin anti-
bodies in the antiphospholipid syndrome: a sys-
tematic review of the literature. Blood, 101,
1827–1832.
Garcia, D., Akl, E.A., Carr, R. & Kearon, C. (2013)
Antiphospholipid antibodies and the risk of
recurrence after a first episode of venous throm-
boembolism: a systematic review. Blood, 122,
817–824.
Girardi, G. (2010) Role of tissue factor in the
maternal immunological attack of the embryo in
the antiphospholipid syndrome. Clinical Reviews
in Allergy and Immunology, 39, 160–165.
Girardi, G., Berman, J., Redecha, P., Spruce, L.,
Thurman, J.M., Kraus, D., Hollmann, T.J.,
Casali, P., Caroll, M.C., Wetsel, R.A., Lambris,
J.D., Holers, V.M. & Salmon, J.E. (2003) Com-
plement C5a receptors and neutrophils mediate
fetal injury in the antiphospholipid syndrome.
Journal of Clinical Investigation, 112, 1644–1654.
Girardi, G., Redecha, P. & Salmon, J.E. (2004)
Heparin prevents antiphospholipid antibody-
induced fetal loss by inhibiting complement
activation. Nature Medicine, 10, 1222–1226.
Glotz, D., Russ, G., Rostaing, L., Legendre, C.,
Chadban, S., Grinyo, J., Mamode, N., Cozzi, E.,
Lebranchu, Y., Sandrini, S., Couzi, L. & Marks,
W. (2015) Eculizumab in Prevention of Acute
Antibody-Mediated Rejection in Sensitized
Deceased-Donor Kidney Transplant Recipients:
1-Year Outcomes. American Transplant Con-
gress, Abstract number: 3039.
Griffiths, M.H., Papadaki, L. & Neild, G.H. (2000)
The renal pathology of primary antiphospho-
lipid syndrome: a distinctive form ofendothelial
injury. QJM : Monthly Journal of the Association
of Physicians, 93, 457–467.
Gris, J.C., Bouvier, S., Molinari, N., Galanaud, J.P.,
Cochery-Nouvellon, E., Mercier, E., Fabbro-
Peray, P., Balducchi, J.P., Mares, P., Quere, I. &
Dauzat, M. (2012) Comparative incidence of a
first thrombotic event in purely obstetric
antiphospholipid syndrome with pregnancy loss:
the NOH-APS observational study. Blood, 119,
2624–2632.
de Groot, P.G. & Meijers, J.C. (2011) beta(2) -Gly-
coprotein I: evolution, structure and function.
Journal of Thrombosis and Haemostasis, 9, 1275–
1284.
de Groot, P.G., Lutters, B., Derksen, R.H., Lisman,
T., Meijers, J.C. & Rosendaal, F.R. (2005) Lupus
anticoagulants and the risk of a first episode of
deep venous thrombosis. Journal of Thrombosis
and Haemostasis, 3, 1993–1997.
Holers, V.M., Girardi, G., Mo, L., Guthridge, J.M.,
Molina, H., Pierangeli, S.S., Espinola, R., Xiao-
wei, L.E., Mao, D., Vialpando, C.G. & Salmon,
ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
J.E. (2002) Complement C3 activation is
required for antiphospholipid antibody-induced
fetal loss. Journal of Experimental Medicine, 195,
211–220.
Ioannou, Y., Pericleous, C., Giles, I., Latchman,
D.S., Isenberg, D.A. & Rahman, A. (2007) Bind-
ing of antiphospholipid antibodies to discontin-
uous epitopes on domain I of human beta(2)-
glycoprotein I: mutation studies including resi-
dues R39 to R43. Arthritis and Rheumatism, 56,
280–290.
Ioannou, Y., Zhang, J.Y., Passam, F.H., Rahgozar,
S., Qi, J.C., GiannakopoulosB, Qi M., Yu, P., Yu,
D.M., Hogg, P.J. & Krilis, S.A. (2010) Naturally
occurring free thiols within b2-glycoprotein I
in vivo: nitrosylation, redox modification by
endothelial cells and regulation of oxidative stress
induced cell injury. Blood, 116, 1961–1970.
Ioannou, Y., Zhang, J.Y., Qi, M., Gao, L., Qi, J.C.,
Yu, D.M., Lau, H., Sturgess, A.D., Vla-
choyiannopoulos, P.G., Moutsopoulos, H.M.,
Rahman, A., Pericleous, C., Atsumi, T., Koike,
T., Heritier, S., Giannakopoulos, B. & Krilis,
S.A. (2011) Novel assays of thrombogenic
pathogenicity in the antiphospholipid syndrome
based on the detection of molecular oxidative
modification of the major autoantigen beta2-
glycoprotein I. Arthritis and Rheumatism, 63,
2774–2782.
Johansson, E., Forsberg, K. & Johnsson, H. (1981)
Clinical and experimental evaluation ofthe
thromboprophylactic effect of hydroxychloro-
quine sulfate after total hip replacement. Hae-
mostasis, 10, 89–96.
Keeling, D., Mackie, I., Moore, G.W., Greer, I.A. &
Greaves, M. (2012) Guidelines on the investiga-
tion and management of antiphospholipid
syndrome. British Journal of Haematology, 157,
47–58.
Kumar, D. & Roubey, R.A. (2010) Use of ritux-
imab in the antiphospholipid syndrome. Current
Rheumatology Reports, 12, 40–44.
Kutteh, W.H. (1996) Antiphospholipid antibody-
associated recurrent pregnancy loss: treatment
with heparin and low-dose aspirin is superior to
low-dose aspirin alone. American Journal of
Obstetrics and Gynecology, 174, 1584–1589.
de Laat, H.B., Derksen, R.H., Urbanus, R.T., Roest,
M. & de Groot, P.G (2004) beta2-glycoprotein
I-dependent lupus anticoagulant highly corre-
lates with thrombosis in the antiphospholipid
syndrome. Blood, 104, 3598–3602.
de Laat, B., Derksen, R.H., Urbanus, R.T. & de
Groot, P.G. (2005) IgG antibodies that recognize
epitope Gly40-Arg43 in domain I of beta 2-gly-
coprotein I cause LAC, and their presence corre-
lates strongly with thrombosis. Blood, 105,
1540–1545.
de Laat, B., Derksen, R.H., van Lummel, M., Pen-
nings, M.T. & de Groot, P.G. (2006) Pathogenic
anti-beta2-glycoprotein I antibodies recognize
domain I of beta2-glycoprotein I only after a
conformational change. Blood, 107, 1916–1924.
de Laat, B., Pengo, V., Pabinger, I., Musial, J., Vos-
kuyl, A.E., Bultink, I.E., Ruffatti, A., Rozman,
Review
B., Kveder, T., de Moerloose, P., Boehlen, F.,
Rand, J., Ulcova-Gallova, Z., Mertens, K. & de
Groot, P.G. (2009) The association between cir-
culating antibodies against domain I of beta2-
glycoprotein I and thrombosis: an international
multicenter study. Journal of Thrombosis and
Haemostasis, 7, 1767–1773.
Lackner, K.J. & M€ uller-Calleja, N. (2016) Patho-
genesis of the antiphospholipid syndrome revis-
ited: time to challenge the dogma. Journal of
Thrombosis and Haemostasis, 6, 1117–1120.
Lambrianides, A., Carroll, C.J., Pierangeli, S.S.,
Pericleous, C., Branch, W., Rice, J., Latchman,
D.S., Townsend, P., Isenberg, D.A., Rahman, A.
& Giles, I.P. (2010) Effects of polyclonal IgG
derived from patients with different clinical
types of the antiphospholipid syndrome on
monocyte signaling pathways. Journal of
Immunology, 184, 6622–6628.
Levine, S.R., Brey, R.L., Tilley, B.C., Thompson,
J.L., Sacco, R.L., Sciacca, R.R., Murphy, A., Lu,
Y., Costigan, T.M., Rhine, C., Levin, B., Triplett,
D.A. & Mohr, J.P. (2004) Antiphospholipid
antibodies and subsequent thrombo-occlusive
events in patients with ischemic stroke. JAMA,
291, 576–584.
Liestol, S., Sandset, P.M., Jacobsen, E.M., Mow-
inckel, M.C. & Wisloff, F. (2007) Decreased
anticoagulant response to tissue factor pathway
inhibitor type 1 in plasmas from patients with
lupus anticoagulants. British Journal of Haema-
tology, 136, 131–137.
Maiti, S.N., Balasubramanian, K., Ramoth, J.A. &
Schroit, A.J. (2008) b-2-glycoprotein 1-depen-
dent macrophage uptake of apoptotic cells:bind-
ing to lipoprotein receptor-related protein
receptor family members. Journal of Biological
Chemistry, 283, 3761–3766.
Mak, A., Cheung, M.W., Cheak, A.A. & Ho, R.C.
(2010) Combination of heparin and aspirin is
superior to aspirin alone in enhancing live births
in patients with recurrent pregnancy loss and
positive anti-phospholipid antibodies: a meta-
analysis of randomized controlled trials and
meta-regression. Rheumatology (Oxford), 49,
281–288.
Malia, R.G., Kitchen, S., Greaves, M. & Preston,
F.E. (1990) Inhibition of activated protein C
and its cofactor protein S by antiphospholipid
antibodies. British Journal of Haematology, 76,
101–107.
Manning, B.D. & Cantley, L.C. (2007) AKT/PKB
signaling: navigating downstream. Cell, 129,
1261–1274.
Manukyan, D., M€ uller-Calleja, N., J€ackel, S., Luch-
mann, K., M€ onnikes, R., Kiouptsi, K., Rein-
hardt, C, Jurk, K., Walter, U. & Lackner, K.J.
(2016) Cofactor-independent human antiphos-
pholipid antibodies induce venous thrombosis
in mice. Journal of Thrombosis and Haemostasis,
14, 1011–1020.
Mcneil, H.P., Simpson, R.J., Chesterman, C.N. &
Krilis, S.A. (1990) Anti-phospholipid antibodies
are directed against a complex antigen that
includes a lipid-binding inhibitor of coagulation:
13
Review
beta 2-glycoprotein I (apolipoprotein H). Pro-
ceedings of the National Academy of Sciences of
the United States of America, 87, 4120–4124.
Mekinian, A., Lazzaroni, M.G., Kuzenko, A., Alijo-
tas-Reig, J., Ruffatti, A., Levy, P., Canti, V.,
Bremme, K., Bezanahary, H., Bertero, T., Dhote,
R., Maurier, F., Andreoli, L., Benbara, A., Tiga-
zin, A., Carbillon, L., Nicaise-Roland, P., Tin-
cani, A. & Fain, O. (2015) The efficacy of
hydroxychloroquine for obstetrical outcome in
anti-phospholipid syndrome: data from a Euro-
pean multicenter retrospective study. Autoimmu-
nity Reviews, 14, 498–502.
Miyakis, S., Lockshin, M.D., Atsumi, T., Branch,
D.W., Brey, R.L., Cervera, R., Derksen, R.H., DE
Groot, P.G., Koike, T., Meroni, P.L., Reber, G.,
Shoenfeld, Y., Tincani, A., Vlachoyiannopoulos,
P.G. & Krilis, S.A. (2006) International consen-
sus statement on an update of the classification
criteria for definite antiphospholipid syndrome
(APS). Journal of Thrombosis and Haemostasis:
JTH, 4, 295–306.
Nayar, R. & Lage, J.M. (1996) Placental changes in
a first trimester missed abortion in maternal sys-
temic lupus erythematosus with antiphospho-
lipid syndrome; a case report and review of the
literature. Human Pathology, 27, 201–206.
Noel, N., Dutasta, F., Costedoat-Chalumeau, N.,
Bienvenu, B., Mariette, X., Geffray, L., Sene, D.,
Chaidi, R.B., Michot, J.M., Fain, O., Darnige, L.,
Ankri, A., Cacoub, P., Piette, J.C. & Saadoun, D.
(2015) Safety and efficacy of oral direct inhibitors
of thrombin and factor Xa in antiphospholipid
syndrome. Autoimmunity Reviews, 14, 680–685.
Nojima, J., Kuratsune, H., Suehisa, E., Iwatani, Y.
& Kanakura, Y. (2005) Acquired activated pro-
tein C resistance associated with IgG antibodies
against beta2-glycoprotein I and prothrombin as
a strong risk factor for venous thromboem-
bolism. Clinical Chemistry, 51, 545–552.
Oku, K., Atsumi, T., Bohgaki, M., Amengual, O.,
Kataoka, H., Horita, T., Yasuda, S. & Koike, T.
(2009) Complement activation in patients with
primary antiphospholipid syndrome. Annals of
the Rheumatic Diseases, 6, 1030–1035.
van Os, G.M., Meijers, J.C., Agar, C., Seron, M.V.,
Marquart, J.A., Akesson, P., Urbanus, R.T.,
Derksen, R.H., Herwald, H., Morgelin, M. &
Groot Pg, D.E. (2011) Induction of anti-beta2 -
glycoprotein I autoantibodies in mice by protein
H of Streptococcus pyogenes. Journal of Throm-
bosis and Haemostasis, 9, 2447–2456.
Ostertag, M.V., Liu, X., Henderson, V. & Pieran-
geli, S.S. (2006) A peptide that mimics the Vth
region of beta-2-glycoprotein I reverses
antiphospholipid-mediated thrombosis in mice.
Lupus, 15, 358–365.
Out, H.J., Kooijman CD, F.A.U., Bruinse HW,
F.A.U. & Derksen, R.H. (1991) Histopathologi-
cal findings in placentae from patients with
intra-uterine fetal death and anti-phospholipid
antibodies. European Journal of Obstetrics, Gyne-
cology, and Reproductive Biology, 41, 179–186.
Parke, A., Maier, D., Wilson, D., Andreoli, J. &
Ballow, M. (1989) Intravenous gamma-globulin,
14
antiphospholipid antibodies, and pregnancy.
Annals of Internal Medicine, 110, 495–496.
Pelkmans, L., Kelchtermans, H., de Groot, P.G.,
Zuily, S., Regnault, V., Wahl, D., Pengo, V. &
de Laat, B. (2013) Variability in exposure of epi-
tope G40-R43 of domain i in commercial anti-
beta2-glycoprotein I IgG ELISAs. PLoS ONE, 8,
e71402.
Pengo, V., Biasiolo, A., Pegoraro, C., Cucchini, U.,
Noventa, F. & Iliceto, S. (2005) Antibody pro-
files for the diagnosis of antiphospholipid syn-
drome. Thrombosis and Haemostasis, 93, 1147–
1152.
Pengo, V., Biasiolo, A., Gresele, P., Marongiu, F.,
Erba, N., Veschi, F., Ghirarduzzi, A., Barcellona,
D. & Tripodi, A. (2007) A comparison of lupus
anticoagulant-positive patients with clinical pic-
ture of antiphospholipid syndrome and those
without. Arteriosclerosis, Thrombosis, and Vascu-
lar Biology, 27, e309–e310.
Pengo, V., Ruffatti, A., Legnani, C., Gresele, P.,
Barcellona, D., Erba, N., Testa, S., Marongiu, F.,
Bison, E., Denas, G., Banzato, A., Padayattil, J.S.
& Iliceto, S. (2010) Clinical course of high-risk
patients diagnosed with antiphospholipid syn-
drome. Journal of Thrombosis and Haemostasis,
8, 237–242.
Pengo, V., Ruffatti, A., Legnani, C., Testa, S.,
Fierro, T., Marongiu, F., De Micheli, V., Gresele,
P., Tonello, M., Ghirarduzzi, A., Bison, E.,
Denas, G., Banzato, A., Padayattil, J.S. & Iliceto,
S. (2011) Incidence of a first thromboembolic
event in asymptomatic carriers of high-risk
antiphospholipid antibody profile: a multicenter
prospective study. Blood, 118, 4714–4718.
Pengo, V., Ruffatti, A., Tonello, M., Cuffaro, S.,
Banzato, A., Bison, E., Denas, G. & Padayattil,
J.S. (2015) Antiphospholipid syndrome: anti-
bodies to Domain 1 of beta2-glycoprotein 1 cor-
rectly classify patients at risk. Journal of
Thrombosis and Haemostasis, 13, 782–787.
Pericleous, C., Ruiz-Limon, P., Romay-Penabad,
Z., Marin, A.C., Garza-Garcia, A., Murfitt, L.,
Driscoll, P.C., Latchman, D.S., Isenberg, D.A.,
Giles, I., Ioannou, Y., Rahman, A. & Pierangeli,
S.S. (2015) Proof-of-concept study demonstrat-
ing the pathogenicity of affinity-purified IgG
antibodies directed to domain I of beta2-glyco-
protein I in a mouse model of anti-phospholi-
pid antibody-induced thrombosis. Rheumatology
(Oxford), 54, 722–727.
Pierangeli, S.S., Liu, X.W., Barker, J.H., Anderson,
G. & Harris, E.N. (1995) Induction of thrombo-
sis in a mouse model by IgG, IgM and IgA
immunoglobulins from patients with the
antiphospholipid syndrome. Thrombosis and
Haemostasis, 5, 1361–1367.
Pierangeli, S.S., Chen, P.P., Raschi, E., Scurati, S.,
Grossi, C., Borghi, M.O., Palomo, I., Harris,
E.N. & Meroni, P.L. (2008) Antiphospholipid
antibodies and the antiphospholipid syndrome:
pathogenic mechanisms. Seminars in Thrombosis
and Hemostasis, 34, 236–250.
Rai, R., Cohen, H., Dave, M. & Regan, L. (1997)
Randomised controlled trial of aspirin and
ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
aspirin plus heparin in pregnant women with
recurrent miscarriage associated with phospho-
lipid antibodies (or antiphospholipid antibod-
ies). BMJ, 314, 253–257.
Rand, J.H., Wu, X.X., Andree, H.A., Lockwood,
C.J., Guller, S., Scher, J. & Harpel, P.C. (1997)
Pregnancy loss in the antiphospholipid-antibody
syndrome–a possible thrombogenic mechanism.
The New England Journal of Medicine, 337, 154–
160.
Rand, J.H., Wu, X.X., Quinn, A.S. & Taatjes, D.J.
(2010a) The annexin A5-mediated pathogenic
mechanism in the antiphospholipid syndrome:
role in pregnancy losses and thrombosis. Lupus,
19, 460–469.
Rand, J.H., Wu, X.X., Quinn, A.S., Ashton, A.W.,
Chen, P.P., Hathcock, J.J., Andree, H.A. & Taat-
jes, D.J. (2010b) Hydroxychloroquine protects
the annexin A5 anticoagulant shield from dis-
ruption by antiphospholipid antibodies: evi-
dence for a novel effect for an old antimalarial
drug. Blood, 115, 2292–2299.
Reynaud, Q., Lega, J.C., Mismetti, P., Chapelle, C.,
Wahl, D., Cathebras, P. & Laporte, S. (2014)
Risk of venous and arterial thrombosis accord-
ing to type of antiphospholipid antibodies in
adults without systemic lupus erythematosus: a
systematic review and meta-analysis. Autoimmu-
nity Reviews, 13, 595–608.
Ridker, P.M. (2009) The JUPITER trial: results,
controversies, and implications for prevention.
Circulation: Cardiovascular Quality and Out-
comes, 2, 279–285.
Rodriguez-Garcia, V., Ioannou, Y., Fernandez-
Nebro, A., Isenberg, D.A. & Giles, I.P. (2015)
Examining the prevalence of non-criteria anti-
phospholipid antibodies in patients with anti-
phospholipid syndrome: a systematic review.
Rheumatology (Oxford), 54, 2042–2050.
Romay-Penabad, Z., Carrera Marin, A.L., Willis,
R., Weston-Davies, W., Machin, S., Cohen, H.,
Brasier, A. & Gonzalez, E.B. (2014) Complement
C5-inhibitor rEV576 (coversin) ameliorates in-
vivo effects of antiphospholipid antibodies.
Lupus, 23, 1324–1326.
Ruffatti, A., Del, R.T., Ciprian, M., Bertero, M.T.,
Sciascia, S., Scarpato, S., Montecucco, C., Rossi,
S., Caramaschi, P., Biasi, D., Doria, A., Ram-
pudda, M., Monica, N., Fischetti, F., Picillo, U.,
Brucato, A., Salvan, E., Vittorio, P., Meroni, P.
& Tincani, A. (2011) Risk factors for a first
thrombotic event in antiphospholipid antibody
carriers: a prospective multicentre follow-up
study. Annals of the Rheumatic Diseases, 70,
1083–1086.
Ruiz-Irastorza, G., Khamashta, M.A., Hunt, B.J.,
Escudero, A., Cuadrado, M.J. & Hughes, G.R.
(2002) Bleeding and recurrent thrombosis in
definite antiphospholipid syndrome: analysis of
a series of 66 patients treated with oral anticoag-
ulation to a target international normalized ratio
of 3.5. Archives of Internal Medicine, 162, 1164–
1169.
Ruiz-Irastorza, G., Hunt, B.J. & Khamashta, M.A.
(2007) A systematic review of secondary

thromboprophylaxis in patients with antiphos-
pholipid antibodies. Arthritis and Rheumatism,
57, 1487–1495.
Ruiz-Irastorza, G., Ramos-Casals, M., Brito-Zeron,
P. & Khamashta, M.A. (2010) Clinical efficacy
and side effects of antimalarials in systemic
lupus erythematosus: a systematic review. Annals
of the Rheumatic Diseases, 69, 20–28.
Ruiz-Irastorza, G., Cuadrado, M.J., Ruiz-Arruza, I.,
Brey, R., Crowther, M., Derksen, R., Erkan, D.,
Krilis, S., Machin, S., Pengo, V., Pierangeli, S.,
Tektonidou, M. & Khamashta, M. (2011) Evi-
dence-based recommendations for the preven-
tion and long-term management of thrombosis
in antiphospholipid antibody-positive patients:
report of a task force at the 13th International
Congress on antiphospholipid antibodies. Lupus,
20, 206–218.
Salmon, J.E., Girardi, G. & Holers, V.M. (2003)
Activation of complement mediates antiphos-
pholipid antibody-induced pregnancy loss.
Lupus, 12, 535–538.
Schaefer, J.K., Mcbane, R.D., Black, D.F., Williams,
L.N., Moder, K.G. & Wysokinski, W.E. (2014)
Failure of dabigatran and rivaroxaban to prevent
thromboembolism in antiphospholipid syn-
drome: a case series of three patients. Thrombo-
sis and Haemostasis, 112, 947–950.
Schmidt-Tanguy, A., Voswinkel, J., Henrion, D.,
Subra, J.F., Loufrani, L., Rohmer, V., Ifrah, N. &
Belizna, C. (2013) Antithrombotic effects of
hydroxychloroquine in primary antiphospho-
lipid syndrome patients. Journal of Thrombosis
and Haemostasis, 11, 1927–1929.
Sciascia, S., Breen, K. & Hunt, B.J. (2015) Rivarox-
aban use in patients with antiphospholipid syn-
drome and previous venous thromboembolism.
Blood Coagulation & Fibrinolysis, 26, 476–477.
ª 2017 John Wiley & Sons Ltd, British Journal of Haematology
Sciascia, S., Hunt, B.J., Talavera-Garcia, E., Lliso,
G., Khamashta, M.A. & Cuadrado, M.J. (2016)
The impact of hydroxychloroquine treatment on
pregnancy outcome in women with antiphos-
pholipid antibodies. American Journal of Obstet-
rics and Gynecology, 214, 273.e1-8.
Shapira, I., Andrade, D., Allen, S.L. & Salmon, J.E.
(2012) Brief report: induction of sustained
remission in recurrent catastrophic antiphos-
pholipid syndrome via inhibition of terminal
complement with eculizumab. Arthritis and
Rheumatism, 64, 2719–2723.
Signorelli, F., Nogueira, F., Domingues, V., Mariz,
H.A. & Levy, R.A. (2016) Thrombotic events in
patients with antiphospholipid syndrome treated
with rivaroxaban: a series of eight cases. Clinical
Rheumatology, 35, 801–805.
Son, M., Wypasek, E., Celinska-Lowenhoff, M. &
Undas, A. (2015) The use of rivaroxaban in
patients with antiphospholipid syndrome: a ser-
ies of 12 cases. Thrombosis Research, 135, 1035–
1036.
Sperber, K., Quraishi, H., Kalb, T.H., Panja, A.,
Stecher, V. & Mayer, L. (1993) Selective regula-
tion of cytokine secretion by hydroxychloro-
quine: inhibition of interleukin 1 alpha (IL-1-
alpha) and IL-6 in human monocytes and T
cells. Journal of Rheumatology, 20, 803–808.
The PROMISE study (Predictors of pRegnancy
outcome: biomarkers In APS and Systemic lupus
Erythematosus). Available at: https://clinicaltria
ls.gov/ct2/show/NCT00198068. (accessed 20 June
2016).
de la Torre, Y.M., Pregnolato, F., D’Amelio, F.,
Grossi, C., Di, S.N., Pasqualini, F., Nebuloni,
M., Chen, P., Pierangeli, S., Bassani, N.,
Ambrogi, F., Borghi, M.O., Vecchi, A., Locati,
M. & Meroni, P.L. (2012) Anti-phospholipid
Review
induced murine fetal loss: novel protective effect
of a peptide targeting the beta2 glycoprotein I
phospholipid-binding site. Implications for
human fetal loss. Journal of Autoimmunity, 38,
J209–J215.
Tripodi, A., Chantarangkul, V., Clerici, M., Negri,
B., Galli, M. & Mannucci, P.M. (2001) Labora-
tory control of oral anticoagulant treatment by
the INR system in patients with the antiphos-
pholipid syndrome and lupus anticoagulant.
Results of a collaborative study involving nine
commercial thromboplastins. British Journal of
Haematology, 115, 672–678.
Willis, R., Gonzalez, E.B. & Brasier, A.R. (2015)
The journey of antiphospholipid antibodies
from cellular activation to antiphospholipid syn-
drome. Current Rheumatology Reports, 17, 16–
0485.
Win, K. & Rodgers, G.M. (2014) New oral antico-
agulants may not be effective to prevent venous
thromboembolism in patients with antiphospho-
lipid syndrome. American Journal of Hematology,
89, 1017.
Xu, C., Mao, D., Holers, V.M., Palanca, B., Cheng,
A.M. & Molina, H. (2000) A critical role for
murine complement regulator crry in fetomater-
nal tolerance. Science, 287, 498–501.
Yu, P., Passam, F.H., Yu, D.M., Denyer, G. & Kri-
lis, S. (2008) b2-glycoprotein I inhibits vascular
endothelial growth factor and basic fibroblast
growth factor induced angiogenesis through its
amino terminaldomain. Journal of Thrombosis
and Haemostasis, 6, 1215–1223.
Zhang, J. & Mccrae, K.R. (2005) Annexin A2
mediates endothelial cell activation by antiphos-
pholipid/anti-beta2 glycoprotein I antibodies.
Blood, 105, 1964–1969.
15