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Study: No benefit from anticoagulant use in Behçet’s disease
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Patients with vascular manifestations of Behçet’s disease who received treatment with anticoagulants did not benefit from the therapy given in addition to immunosuppressant drugs, according to results from study of practices in Turkish rheumatology clinics.
A retrospective study of 936 patients with Behçet’s disease (BD) from 15 rheumatology clinics in Turkey was conducted. Mean disease duration was 7.9 years. Patients’ mean age was 37.6 years, and 589 of the patients were men. Demographic data collected included clinical characteristics of the disease and first vascular event, relapses, treatment protocols and data about complications.
Corticosteroids used for treatment included methotrexate, azathioprine, cyclophosphamide, infliximab or interferon-alpha.
Vascular Behçet’s disease (VBD) developed in 260 patients (27.7%) during follow-up, 86.2% of whom were men. Thrombophilic factors were evaluated in 88 patients (34.9%), and 34 patients (38.7%) had thrombophilic disorders. Vascular involvement was the presenting symptom at first diagnosis in 57.3% of patients, and 16.5% of patients were switched from other immunosuppressants to corticosteroids.
Anticoagulants were administered to 59.8% of patients with VBD for a median duration of 13 months. Minor hemorrhage was observed in seven of the patients taking anticoagulants (4.7%).
Vascular relapse occurred in 86 patients with VBD (32.9%), whereas 14 (16.3%) were actively taking only anticoagulants and 32.6% were untreated.
The duration of treatment was similar between those who relapsed and those who did not, but relapse was significantly lower in patients taking immunosuppressive agents (25.3% vs. 85.7%) and significantly higher in the group taking anticoagulants alone (91.6% vs. 29.1%), according to the researchers. No significant relapse rate was seen between patients with and without thrombophilic factors.
The researchers concluded no additional benefits were observed with treatment of VBD with anticoagulants. – by Shirley Pulawski
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Leonard H. Calabrese, DO
One of the most perplexing challenges I have faced is how to treat thrombo-occlusive complications of Behçet’s disease. Such complications are not uncommon but Behçet’s disease is in the United States and it goes against our inclinations to withhold anticoagulation in face of such occlusive vasculopathy.
The EULAR guidelines for Behçet’s disease clearly recommend immunosuppression leaving a question as to the role of anticoagulation unanswered. In fact, in a survey of clinicians published in 2012, Tayer-Shifman and colleagues were twice as prone to anticoagulant as their Turkish colleagues.
The present study by Alibaz-Oner and colleagues goes a way toward answering this unresolved issue by examining a large cohort of vascular Behçet’s disease patients (n=260) from an overall cohort of 936 patients. While retrospective in design, they found that patients treated with immunosuppressives overall did better with lower relapse rates. Relapse was associated with shorter courses of immunosuppressives and anticoagulants, while overall safe, were not protective. Clearly these are imperfect data but add credence to the European strategy of immunosuppression, often without anticoagulants.
I am comforted by this study but still have lingering concerns there may be an advantage to short-term anticoagulation with long-term immunosuppression. The underlying procoagulant is clearly vasculitis but the sinister pathology is thrombosis. When vasculitis resolves, then anticoagulation is no longer needed. This will be a difficult study to design and execute but it would be an important contribution.
Reference:
Tayer-Shifman OE, et al. Clin Exp Rheumatol. 2012;doi: doi:10.1097/MD.0000000000000494.
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