Antiphospholipid Syndrome Committee of the Brazilian Society of Rheumatology position statement on the use of direct oral anticoagulants (DOACs) in antiphospholipid syndrome (APS)

Abstract

Background The term Direct Oral Anticoagulants (DOACs) refers to a group of drugs that inhibit factor Xa or thrombin. Even though their use for treating different thrombotic or prothrombotic conditions is increasing recently, there is no compelling evidence indicating that those medications are safe in all antiphospholipid syndrome (APS) patients. Methodology To address this issue, specialists from the Antiphospholipid Syndrome Committee of the Brazilian Society of Rheumatology performed a comprehensive review of the literature regarding DOACs use in APS to answer the three following questions: (1) potential mechanisms of action of these drugs that could be relevant to APS pathogenesis, (2) DOACs interference on lupus anticoagulant testing, and (3) the efficacy of DOACs in APS. Position statement After critically reviewing the relevant evidence, the authors formulated 8 Position Statements about DOACs use in APS. Conclusion DOACs should not be routinely used in APS patients, especially in those with a high-risk profile (triple positivity to aPL, arterial thrombosis, and recurrent thrombotic events). In addition, DOACs interferes with LA testing, leading to false-positive results in patients investigating APS.

CoaguChek® XS versus standard laboratory prothrombin time for anticoagulant monitoring in patients with antiphospholipid syndrome

“…7 However, guidance from scientific societies is variable about the use of DOACs in APS, and states that these drugs should not be used in high-risk patients (arterial thrombosis, triple positivity to aPL, small vessel thrombosis, and heart valve disease), non-adherent patients, or those with recurrent thrombosis while on therapeutic intensity VKA. [8][9][10][11] Therefore, anticoagulation with a VKA remains the standard of care for treating APS patients. 12 The laboratory test used for monitoring VKA anticoagulation is prothrombin time (PT), a worldwide, standardized coagulation test, expressed as international normalized ratio (INR).…”

Anticoagulation: An overview of pharmacological agents and therapeutic implications in rheumatology

“…factors increasing hypercoagulability in rheumatic disorders encompass increased tissue factor expression, increased microparticles (levels of platelet-derived microparticles are elevated), platelet activation, increased fibrinogen level through inflammation, hypercoagulability via complement activation and interaction with coagulation factors, reduced thrombomodulin, as well as increased plasminogen activator inhibitor-1 (pAi-1) (33)(34)(35). statak proteina c, proteina s i antitrombina iii, kao i prisutnost antifosfolipidnih (apl) protutijela (41,42,43). sistemski eritemski lupus neovisni je čimbenik rizika i za arterijske i za venske tromboze i posebno je povezan s prisutnošću apl protutijela.…”

Managing Antiphospholipid Syndrome in Children and Adolescents: Current and Future Prospects

“…Direct oral anticoagulants (DOACs) selectively target factors in the coagulation pathway, mainly factor Xa and thrombin, and are widely used in adult patients for the prevention and treatment of thrombosis in several contexts [109]. They have advantages over other anticoagulant options, particularly for children and adolescents, and they do not require laboratory monitoring, can be administered orally, have a short halflife, and have little interaction with other drugs and food [110][111][112]. However, some drugs, such as anticonvulsants, immunosuppressants (cyclosporin and tacrolimus), and nonsteroidal anti-inflammatory drugs, may reduce the efficacy of DOACs or increase bleeding episodes [113,114].…”

“…Although the use of DOACs represents a potential advance for the treatment and prophylaxis of thrombus in children and adolescents [126][127][128][129][130][131], guidance from professional organizations recommends strictly avoiding the use of DOACs in patients with APS with arterial, small vessel, and recurrent thrombosis or cardiac valvular disease and in those with triple aPL positivity [88,106,112]. This recommendation was based on clinical trials with negative outcomes for DOAC-treated patients.…”