What is the appropriate anticoagulation strategy for thrombotic antiphospholipid syndrome?

Abstract

Antiphospholipid syndrome (APS) is an autoimmune prothrombotic disorder mediated by a heterogeneous group of autoantibodies collectively known as antiphospholipid antibodies (aPL). They include lupus anticoagulant (LA), IgG and IgM anticardiolipin antibodies (aCL) and anti-b2-glycoprotein I (anti-b2GPI) antibodies. It has been shown that those patients with all three aPL (triple positive) are at highest risk of both a first thrombotic event and of a recurrence, despite anticoagulation. In response to publication of a meta-analysis and a randomised controlled trial assessing the safety and efficacy of rivaroxaban versus warfarin in triplepositive APS with venous and/or arterial thrombosis, the Medicines and Healthcare Products Regulatory Agency (MHRA) and European Medicines Agency (EMA) issued recommendations that direct-acting oral anticoagulant (DOACs) should not be used for secondary prevention of thrombosis in all APS patients (although they did draw specific attention to the high risk of triple-positive patients). As there is less evidence for patients with single-or dual-positive patients with APS, this may be an over-interpretation of the data. In this review, we explore the available evidence on safety and efficacy of DOACs in thrombotic APS, the problem of detecting LA while on DOAC, and provide some practical guidance for managing this problem.

How we approach thrombosis risk in children with COVID‐19 infection and MIS‐C

“…However, use of antiviral therapies may prohibit its use due to drug interaction and risk of supra‐therapeutic anticoagulation 21 . DOACs are also not recommended for those with triple‐positive high risk for antiphospholipid syndrome (APS) 50 . As this patient had normal renal function and no other contraindication for DOAC use, she was transitioned to Apixaban at 2.5 mg by mouth twice daily .…”

Direct oral anticoagulants for unusual‐site venous thromboembolism

“…Since warfarin also crosses the placenta, LMWH is the preferred drug antenatally; however, warfarin can be considered during the puerperium. In addition, DOACs are not recommended in patients with severe forms of thrombophilia, such as antiphospholipid syndrome with triple positivity 114 …”

“…Since warfarin also crosses the placenta, LMWH is the preferred drug antenatally; however, warfarin can be considered during the puerperium. In addition, DOACs are not recommended in patients with severe forms of thrombophilia, such as antiphospholipid syndrome with triple positivity 114. 8 | IS TH 2 02 0 CONG RE SS REP ORTThe results of several studies on the use of the DOACs in unusualsite VTE were presented during the ISTH 2020 virtual congress.Serrao et al115 evaluated patients with SVT who were candidates for long-term anticoagulation and described similar rates of recurrent thrombosis between those shifted to DOACs and those continued on VKAs.…”

Review of coagulation preanalytical variables with update on the effect of direct oral anticoagulants

“…Perhaps, the most interesting consideration for testing patients on DOACs is those patients suspected for high‐risk (triple positivity) antiphospholipid antibody syndrome (APS), as treatment using rivaroxaban in this patient population has demonstrated to be not as effective as warfarin, and thus these patients may be considered for alternative anticoagulant therapy, 37 but further studies are warranted. However, identification of the lupus anticoagulant, a chronometric or clot‐based assay, for the require diagnosis of APS, 38 can be challenging in the presence of DOACs, given their interference in these assays 39‐43 .…”