Use of direct oral anticoagulants in antiphospholipid syndrome.
J Thromb Haemost. 2018 Apr 06;:
Authors: Cohen H, Efthymiou M, Isenberg D
The direct oral anticoagulants (DOACs) are therapeutic alternatives to warfarin and other vitamin K antagonists (VKAs), and the standard of care for many indications. VKAs are conventional therapy for the treatment and secondary thromboprophylaxis of thrombotic antiphospholipid syndrome (APS), but are often problematic due to the variable sensitivity of thromboplastins to lupus anticoagulant. Thus, the International Normalised Ratio may not accurately reflect anticoagulation intensity, or be clinically effective. Definition of the current role of DOACs in APS is based on limited clinical trial data and information from other sources, including manufacturers' data, case series or cohort studies and expert consensus. The RAPS randomised controlled trial (RCT), that had a laboratory surrogate primary outcome measure, suggests that rivaroxaban offers the potential to be an effective and convenient alternative to warfarin in thrombotic APS patients with a single VTE event requiring standard intensity anticoagulation. However, further studies, in particular, acquisition of better long-term efficacy and safety data, are needed before it can be widely recommended. APS patients are clinically heterogeneous, with the risk of recurrent thrombosis and the intensity of anticoagulation influenced by their clinical phenotype and risk profile. DOAC trials involving homogeneous thrombotic APS populations, with aPL status well defined, will help to optimise the appropriate treatment in APS patient subgroups. Ongoing and emerging DOAC RCTs should provide further information to guide the use of DOACs in APS. Optimal identification of APS patients is a key step in working towards improved therapeutic strategies in these individuals. This article is protected by copyright. All rights reserved.
PMID: 29624847 [PubMed - as supplied by publisher]