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

Abstract

Patients with thrombotic antiphospholipid syndrome (APS) require long-term anticoagulation due to the high-thrombotic recurrence risk. Vitamin K antagonists (VKA) have been traditionally considered the standard of care in thrombotic APS. Nevertheless, the risk of recurrence persists with VKA. There are publications considering different intensities of anticoagulation with VKA; however, the standard-intensity anticoagulation (international normalized ratio between 2.0 and 3.0) is the most recommended. Furthermore, there is no consensus on the role of antiplatelet treatment in thrombotic APS. Nonvitamin K antagonist oral anticoagulants (NOACs) have emerged as an alternative to VKA for many indications. There are, however, discrepancies regarding the management with NOACs in thrombotic APS. In this review, we update the different clinical trials with NOACs in venous, arterial, and microvascular thrombosis and suggest how these patients should be managed in agreement with the expert panels. Although scarce data are published regarding the current role of NOACs in thrombotic APS, the clinical trials failed to demonstrate noninferiority of NOACs compared with VKA, especially in patients with triple antiphospholipid antibodies positivity and/or arterial thrombosis. Single or double antiphospholipid positivity should be analyzed on a case-by-case basis. In addition, we focus on different areas of uncertainty that still remain in thrombotic APS and NOACs. To summarize, emerging clinical trials are needed to provide robust data on the management of thrombotic APS.

Simplified Method for Removing Direct Oral Anticoagulant Interference in Mechanical Coagulation Test Systems—A Proof of Concept

“…These drugs are used to treat or prevent thrombosis in a wide range of conditions, including atrial fibrillation and deep vein thrombosis (DVT). In other prothrombotic conditions, such as antiphospholipid syndrome (APS), the classical vitamin K antagonists (VKAs), including warfarin, may be preferred over DOACs [3]. Irrespective, DOACs cause interference in a wide range of hemostasis assays, especially coagulation-based assays, where they will inevitably prolong clot times [4][5][6][7][8][9][10][11].…”

Management of Thrombosis in a Patient with Three Thrombophilic Disorders

“…Although some published data suggest DOACs as an alternative to VKA in inherited thrombophilia, 1 the concerns for DOACs in patients with antiphospholipid syndrome, a severe acquired thrombophilia, strongly encourage further studies. 13 …”

Recent Advances in Thrombosis and Hemostasis—Part IX

“…Marco-Rico and Marco-Vera have now reviewed the literature on trials with NOACs for VTE, arterial thrombosis, or microvascular thrombosis in patients with APS. 9 They summarize, at the end, the current treatment recommendations and the unmet needs.…”