Antiphospholipid syndrome and challenges with direct oral anticoagulants

Abstract

Direct oral anticoagulants have become the mainstay of the management of venous thromboembolism and atrial fibrillation, and long-term anticoagulation is indicated for those at high risk of further thrombotic events. This includes patients diagnosed with antiphospholipid syndrome, for whom the ‘triple positive’ laboratory combination of lupus anticoagulant, β2-glycoprotein-1 and anti-cardiolipin antibodies signify those at greatest risk. Data from meta-analysis and randomised control trials have raised the concern that direct oral anticoagulants may be less effective than vitamin K antagonists for the prevention of thrombosis in patients with thrombotic antiphospholipid syndrome, particularly those with the triple positive profile. This article reviews the diagnosis of thrombotic antiphospholipid syndrome, strategies for testing without interruption of anticoagulation, evidence concerning the safety of direct oral anticoagulants in this setting, and the implications for current investigation and management of unprovoked venous thromboembolism.

The trends in the incidence and thrombosis-related comorbidities of antiphospholipid syndrome: a 14-year nationwide population-based study

“…APS-related comorbidities in the study population that were considered included diabetes mellitus [ 10 ] (ICD-9-CM 250), hypertension [ 11 – 13 ] (ICD-9-CM 401–405), hyperlipidemia [ 14 ] (ICD-9-CM 272), stroke [ 10 ](ICD-9-CM 430–438), heart failure [ 15 ] (ICD-9-CM 428), atrial fibrillation [ 16 ] (ICD-9-CM 427.32), myocardial infarction [ 17 ] (ICD-9-CM 410–410.9, 412), peripheral arterial occlusive disease [ 10 ] (PAOD; ICD-9-CM 440–444), chronic kidney disease [ 13 ] (ICD-9-CM 580–589), chronic obstructive pulmonary disease [ 18 ](COPD; ICD-9-CM 490–496), deep vein thrombosis [ 10 ] (ICD-9-CM 451.1, 451.2, 451.8, and 453), pulmonary embolism [ 10 ] (ICD-9-CM 415.1), systemic lupus erythematosus [ 10 ] (SLE; ICD-9-CM 710.0), rheumatoid arthritis [ 19 ] (ICD-9-CM 714), systemic sclerosis [ 20 ] (ICD-9-CM 710.1), Sjogren’s syndrome [ 21 ] (ICD-9-CM 710.2), and polymyositis [ 22 ] (ICD-9-CM 710.4).…”

Thrombotic Antiphospholipid Syndrome and Direct Oral Anticoagulants: Unmet Needs and Review of the Literature

“…Catastrophic APS is a life-threatening disease characterized by a multiorgan failure within a week of presentation, usually associated with small-vessel thrombosis. 9…”

“…11 Of note, triple positive aPL patients, mainly when LA is included, represent the highest thrombotic risk, with an estimated annualized incidence of 5.3%. 8 9 Therefore, long-term anticoagulation is required in thrombotic APS. 12 13…”

“…11 Of note, triple positive aPL patients, mainly when LA is included, represent the highest thrombotic risk, with an estimated annualized incidence of 5.3%. 8,9 Therefore, long-term anticoagulation is required in thrombotic APS. 12,13 Vitamin K antagonists (VKA) have been considered the standard of care for treatment and secondary prophylaxis of thrombotic APS.…”

“…Catastrophic APS is a life-threatening disease characterized by a multiorgan failure within a week of presentation, usually associated with small-vessel thrombosis. 9 APS implies a high thrombotic risk, mainly related to the proposal that aPL promotes thrombus formation and platelet activation. 2 APL can upregulate tissue factor expression, a strong anticoagulation initiator.…”