From the Guidelines
The recommended test for this patient is antiphospholipid antibody testing, which should include lupus anticoagulant, anticardiolipin antibodies, and anti-β2 glycoprotein I antibodies. This patient presents with clinical features consistent with systemic lupus erythematosus (SLE), including symmetrical small joint pain and swelling, malar rash, proteinuria, and positive ANA and anti-dsDNA antibodies. SLE patients have an increased risk of developing antiphospholipid syndrome (APS), which can cause both arterial and venous thrombosis as well as pregnancy complications including recurrent spontaneous abortions. Detecting these antibodies is crucial for risk stratification and management decisions.
Key Points to Consider
- According to the 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases 1, antiphospholipid antibody testing is essential for patients with SLE or SLE-like disease.
- The presence of antiphospholipid antibodies modifies the recommendations for management, including the use of prophylactic anticoagulation during high-risk periods and possibly long-term anticoagulation if there is a history of thrombosis.
- For pregnancy planning, close monitoring and the use of low-dose aspirin and/or low molecular weight heparin may be required to reduce the risk of pregnancy complications, as suggested by the 2020 American College of Rheumatology guideline 1.
- Testing should be repeated after 12 weeks if positive to confirm persistence, which is required for the diagnosis of antiphospholipid syndrome, as recommended by the laboratory criteria for antiphospholipid syndrome 1.
Management Considerations
- Patients with positive antiphospholipid antibodies should be managed in collaboration with a clinical pathologist and a clinician skilled in interpreting the data, as emphasized in the laboratory criteria for antiphospholipid syndrome 1.
- The use of hormonal contraception should be carefully weighed against the risk of thrombosis in patients with positive antiphospholipid antibodies, as noted in the EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy, and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome 1.
From the Research
Assessment of Thrombotic Events and Spontaneous Abortion Risk in SLE Patients
To assess the risk of thrombotic events and spontaneous abortion in a patient with Systemic Lupus Erythematosus (SLE) presenting with symmetrical small joint pain and swelling, malar rash, proteinuria, positive Antinuclear Antibody (ANA) and anti-double-stranded Deoxyribonucleic Acid (DNA) antibodies, the following tests should be considered:
- Antiphospholipid antibody testing, including:
- These tests are essential for diagnosing Antiphospholipid Syndrome (APS), a prothrombotic condition that increases the risk of thrombosis and pregnancy-related morbidity 2, 5, 6, 4
Rationale for Test Selection
The selected tests are based on the following rationale:
- APS is a known complication of SLE, and antiphospholipid antibodies are associated with an increased risk of thrombosis and spontaneous abortion 2, 5, 6, 4
- The presence of LA, aCL, and aβ2GPI antibodies is a strong predictor of thrombotic risk, and triple positivity is associated with a high risk of thrombotic events 5, 4
- The use of solid-phase assays for aCL and aβ2GPI antibodies can help identify patients at risk of thrombosis, even in the presence of anticoagulant therapy 2, 5
Clinical Utility of Test Results
The results of these tests can help clinicians:
- Diagnose APS and assess the risk of thrombotic events and spontaneous abortion in SLE patients 2, 5, 6, 4
- Guide treatment decisions, including the use of anticoagulant therapy to prevent thrombotic events 2, 5, 4
- Monitor patients for the development of thrombotic complications and adjust treatment accordingly 3, 6