Materiały źródłowe

• #1 Prevention of thrombosis in antiphospholipid syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6142449/

  Antiphospholipid syndrome (APS) is an acquired autoimmune condition characterized by thrombotic events, pregnancy morbidity, and laboratory evidence of antiphospholipid antibodies (aPL). Management of these patients includes the prevention of a first thrombotic episode in at-risk patients (primary prevention) and preventing recurrent thrombotic complications in patients with a history of thrombosis (secondary prevention). […] Although antithrombotic options for secondary prevention of venous thromboembolism (VTE) have been evaluated in clinical trials, studies in primary prevention of asymptomatic aPL-positive patients are needed. Primary prevention with aspirin may be considered in asymptomatic patients who have a high-risk aPL profile, particularly if additional risk factors are present. Secondary prevention with long-term anticoagulation is recommended based on estimated risks of VTE recurrence, although routine evaluation of thrombotic risk can assist in determining whether ongoing anticoagulation is warranted.

• #2 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9741036/

  Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by the persistent positivity of antiphospholipid antibodies (aPLA) together with thrombosis or obstetrical complications. […] The mainstay of treatment of APS is anticoagulant therapy. However, its optimal intensity in different presentations of the disease remains undefined. Moreover, decision on which patients with aPLA would benefit from an antithrombotic prophylaxis and its optimal intensity are challenging because of the lack of stratification tools for the risk of thrombosis. […] According to the most recent guidelines, primary antithrombotic prophylaxis with low dose (75-100 mg/day) aspirin (LDA) in high-risk profile aPLA patients without history of thrombosis is recommended. […] In our view, when the evidence of the efficacy of antithrombotic prophylaxis is uncertain, performing a complete thrombophilia work-up may help in the decision making.

• #3 Prevention of thrombosis in antiphospholipid syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6142449/

  Evaluation of the thrombotic risk in patients with aPL and knowledge of the bleeding risk associated with antithrombotic agents is required to properly weigh the risks and benefits of administering antithrombotic therapy in the primary and secondary prevention settings. […] In non-SLE individuals with aPL and no previous thrombosis, low-dose aspirin was given a 2C recommendation (based on low or very low quality evidence) for use in those with a high-risk aPL profile, especially in the presence of additional thrombotic risk factors. […] In patients with SLE and aPL (positive LA, isolated persistent aCL at medium-high titers), primary thromboprophylaxis with hydroxychloroquine and low-dose aspirin is recommended. […] The rates of VTE recurrence in patients with APS have generally exceeded bleeding risk associated with anticoagulant use, resulting in the recommendation from a number of guideline panels to consider long-term anticoagulation in patients with thrombosis and APS. […] In patients with APS, prevention of a recurrent thrombotic event (secondary prevention) is critical.

• #4 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9741036/

  Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by the persistent positivity of antiphospholipid antibodies (aPLA) together with thrombosis or obstetrical complications. […] The mainstay of treatment of APS is anticoagulant therapy. However, its optimal intensity in different presentations of the disease remains undefined. Moreover, decision on which patients with aPLA would benefit from an antithrombotic prophylaxis and its optimal intensity are challenging because of the lack of stratification tools for the risk of thrombosis. […] According to the most recent guidelines, primary antithrombotic prophylaxis with low dose (75-100 mg/day) aspirin (LDA) in high-risk profile aPLA patients without history of thrombosis is recommended. […] In our view, when the evidence of the efficacy of antithrombotic prophylaxis is uncertain, performing a complete thrombophilia work-up may help in the decision making.

• #5 EULAR recommendations for the management of antiphospholipid syndrome in adults | Annals of the Rheumatic Diseases

  https://ard.bmj.com/content/78/10/1296

  The objective was to develop evidence-based recommendations for the management of antiphospholipid syndrome (APS) in adults. […] Risk modification includes screening for and management of cardiovascular and venous thrombosis risk factors, patient education about treatment adherence, and lifestyle counselling. […] Low-dose aspirin (LDA) is recommended for asymptomatic aPL carriers, patients with systemic lupus erythematosus without prior thrombotic or obstetric APS, and non-pregnant women with a history of obstetric APS only, all with high-risk aPL profiles. […] In women with prior obstetric APS, combination treatment with LDA and prophylactic dosage heparin during pregnancy is recommended. […] These recommendations aim to guide treatment in adults with APS. High-quality evidence is limited, indicating a need for more research.

• #6 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9741036/

  Due to the high risk of venous and arterial thrombosis associated with the use of combined oral contraceptives in young women, their use should be avoided in patients with triple positive aPLA. […] In patients with a high-risk aPLA profile and no history of thrombosis or obstetrical complications, prophylaxis with LDA is suggested, although with low evidence. […] Pregnant women with a history of thrombotic APS should be treated with LDA associated with LMWH at therapeutic doses. […] It has been proposed that women with a history of obstetric APS can receive an antithrombotic prophylaxis with variable intensity according to the type of pregnancy complications. […] In general, patients with APS have indication to continue lifelong anticoagulant treatment because of the high risk of recurrent thrombosis.

• #7 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://www.mdpi.com/2077-0383/11/23/6984

  In patients with a high-risk aPLA profile and no history of thrombosis or obstetrical complications, prophylaxis with LDA is suggested, although with low evidence. […] Pregnant women with a history of thrombotic APS should be treated with LDA associated with LMWH at therapeutic doses. […] In case of ≥3 spontaneous miscarriages or ≥3 fetal loss, LDA and heparin at prophylactic doses are recommended; in case of delivery <34 weeks of gestation for eclampsia, severe pre-eclampsia, or placental insufficiency LDA or LDA with heparin at prophylactic dose is suggested. [...] In women with recurrent obstetrical complications despite LDA and heparin at prophylactic doses, intensification to therapeutic heparin is suggested and, in selected cases, addition of hydroxychloroquine, steroids or intravenous immunoglobulin may be considered.

• #8 Antiphospholipid Syndrome and Its Management

  https://www.uspharmacist.com/article/antiphospholipid-syndrome-and-its-management

  The use of low-dose aspirin (LDA) for primary thrombosis prevention in APS is controversial based on the low quality of evidence and the lack of prospective data showing that LDA is effective. […] A report from the 16th International Congress on Antiphospholipid Antibodies recommends consideration of LDA for primary prevention of thrombosis on a case-by-case basis in certain patient groups. LDA should be considered in asymptomatic aPL carriers with or without SLE and patients with prior obstetric APS who have persistent LA, double or triple aPL positivity, or persistently high aPL titer. […] According to EULAR guidelines, prophylaxis with LDA at a dosage of 75 mg to 100 mg daily is recommended in patients with a high-risk profile and may be considered in patients with a low-risk profile.

• #9 Management of Antiphospholipid Syndrome

  https://www.mdpi.com/2227-9059/8/11/508

  The decision of primary prophylaxis should be taken after a patient-centred risk stratification, which includes aPL profile (number, titer, isotype), coexistence of other auto-immune disease or an inherited thrombophilia, and cardiovascular risk factors. […] EULAR recommends primary prophylaxis with LDA (75–100 mg/day) in asymptomatic aPL carriers in the following circumstances: (1) high-risk aPL profile with or without traditional risk factors, (2) patients with SLE and high-risk aPL profile, and (3) non-pregnant women with a history of obstetric APS only. […] In summary, the management of APS should be patient centred, taking into account risk stratification, clinical phenotype, and comorbidities.

• #10 Management of Antiphospholipid Syndrome

  https://www.mdpi.com/2227-9059/8/11/508

  The decision of primary prophylaxis should be taken after a patient-centred risk stratification, which includes aPL profile (number, titer, isotype), coexistence of other auto-immune disease or an inherited thrombophilia, and cardiovascular risk factors. […] EULAR recommends primary prophylaxis with LDA (75–100 mg/day) in asymptomatic aPL carriers in the following circumstances: (1) high-risk aPL profile with or without traditional risk factors, (2) patients with SLE and high-risk aPL profile, and (3) non-pregnant women with a history of obstetric APS only. […] In summary, the management of APS should be patient centred, taking into account risk stratification, clinical phenotype, and comorbidities.

• #11 EULAR recommendations for the management of antiphospholipid syndrome in adults | Annals of the Rheumatic Diseases

  https://ard.bmj.com/content/78/10/1296

  In asymptomatic aPL carriers (not fulfilling any vascular or obstetric APS classification criteria) with a high-risk aPL profile with or without traditional risk factors, prophylactic treatment with low-dose aspirin (LDA) (75-100 mg daily) is recommended. […] Treatment with LDA for patients with SLE and high-risk aPL profile is supported by a subanalysis of eight studies, mostly observational, in a meta-analysis. […] In patients with definite APS and first venous thrombosis: Treatment with VKA with a target INR 2-3 is recommended. […] Rivaroxaban should not be used in patients with triple aPL positivity due to the high risk of recurrent events. […] In women with a high-risk aPL profile but no history of thrombosis or pregnancy complications (with or without SLE), treatment with LDA (75-100 mg/day) during pregnancy should be considered. […] In women with a history of obstetric APS only (no prior thrombotic events), with or without SLE: combination treatment with LDA and heparin at prophylactic dosage during pregnancy is recommended.

• #12 Prevention of thrombosis in antiphospholipid syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6142449/

  Evaluation of the thrombotic risk in patients with aPL and knowledge of the bleeding risk associated with antithrombotic agents is required to properly weigh the risks and benefits of administering antithrombotic therapy in the primary and secondary prevention settings. […] In non-SLE individuals with aPL and no previous thrombosis, low-dose aspirin was given a 2C recommendation (based on low or very low quality evidence) for use in those with a high-risk aPL profile, especially in the presence of additional thrombotic risk factors. […] In patients with SLE and aPL (positive LA, isolated persistent aCL at medium-high titers), primary thromboprophylaxis with hydroxychloroquine and low-dose aspirin is recommended. […] The rates of VTE recurrence in patients with APS have generally exceeded bleeding risk associated with anticoagulant use, resulting in the recommendation from a number of guideline panels to consider long-term anticoagulation in patients with thrombosis and APS. […] In patients with APS, prevention of a recurrent thrombotic event (secondary prevention) is critical.

• #13 EULAR recommendations for the management of antiphospholipid syndrome in adults | Annals of the Rheumatic Diseases

  https://ard.bmj.com/content/78/10/1296

  The objective was to develop evidence-based recommendations for the management of antiphospholipid syndrome (APS) in adults. […] Risk modification includes screening for and management of cardiovascular and venous thrombosis risk factors, patient education about treatment adherence, and lifestyle counselling. […] Low-dose aspirin (LDA) is recommended for asymptomatic aPL carriers, patients with systemic lupus erythematosus without prior thrombotic or obstetric APS, and non-pregnant women with a history of obstetric APS only, all with high-risk aPL profiles. […] In women with prior obstetric APS, combination treatment with LDA and prophylactic dosage heparin during pregnancy is recommended. […] These recommendations aim to guide treatment in adults with APS. High-quality evidence is limited, indicating a need for more research.

• #14 Management of Antiphospholipid Syndrome

  https://www.mdpi.com/2227-9059/8/11/508

  The decision of primary prophylaxis should be taken after a patient-centred risk stratification, which includes aPL profile (number, titer, isotype), coexistence of other auto-immune disease or an inherited thrombophilia, and cardiovascular risk factors. […] EULAR recommends primary prophylaxis with LDA (75–100 mg/day) in asymptomatic aPL carriers in the following circumstances: (1) high-risk aPL profile with or without traditional risk factors, (2) patients with SLE and high-risk aPL profile, and (3) non-pregnant women with a history of obstetric APS only. […] In summary, the management of APS should be patient centred, taking into account risk stratification, clinical phenotype, and comorbidities.

• #15 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9741036/

  Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by the persistent positivity of antiphospholipid antibodies (aPLA) together with thrombosis or obstetrical complications. […] The mainstay of treatment of APS is anticoagulant therapy. However, its optimal intensity in different presentations of the disease remains undefined. Moreover, decision on which patients with aPLA would benefit from an antithrombotic prophylaxis and its optimal intensity are challenging because of the lack of stratification tools for the risk of thrombosis. […] According to the most recent guidelines, primary antithrombotic prophylaxis with low dose (75-100 mg/day) aspirin (LDA) in high-risk profile aPLA patients without history of thrombosis is recommended. […] In our view, when the evidence of the efficacy of antithrombotic prophylaxis is uncertain, performing a complete thrombophilia work-up may help in the decision making.

• #16 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://www.mdpi.com/2077-0383/11/23/6984

  Patients with aPLA have an increased risk not only of recurrent, but also of first thrombotic events, and primary prophylaxis is of pivotal importance. […] According to the most recent guidelines, primary antithrombotic prophylaxis with low dose (75–100 mg/day) aspirin (LDA) in high-risk profile aPLA patients without history of thrombosis is recommended. […] However, the use of low molecular weight heparin (LMWH) in high-risk situations such as postoperative periods, lower limb fracture, immobilization, hospitalization, pregnancy/puerperium or central venous catheter placement is widely accepted, as for all other severe thrombophilia abnormalities. […] Due to the high risk of venous and arterial thrombosis associated with the use of combined oral contraceptives in young women, their use should be avoided in patients with triple positive aPLA.

• #17 :: JKMS :: Journal of Korean Medical Science

  https://jkms.org/DOIx.php?id=10.3346/jkms.2021.36.e24

  During pregnancy, heparin plus LDA is recommended. […] Most importantly, a tailored approach and patient-oriented treatment are mandatory. […] Primary thrombo-prophylaxis is generally not recommended for patients who are positive for aPL but have no history of thrombosis, as relatively little is known about the risk of the first thromboembolism and the protective effects of LDA or anticoagulants in this population. […] In high risk situations, such as during extended immobilization and during post-operation and postpartum periods, thrombo-prophylaxis reduced the risk of thrombosis in aPL carriers. […] Antepartum: It is unclear whether pregnant women with aPL but no history of the clinical features of APS are at increased risk for obstetric morbidity or thrombosis during pregnancy. […] The majority of the Advisory Board of the Tenth aPL Antibodies recommended that pregnant women positive for aPL be treated with LDA, and LDA is generally recommended during pregnancy or at the beginning of attempting pregnancy, especially in women at high risk of pre-eclampsia.

• #18 Prevention of thrombosis in antiphospholipid syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6142449/

  Evaluation of the thrombotic risk in patients with aPL and knowledge of the bleeding risk associated with antithrombotic agents is required to properly weigh the risks and benefits of administering antithrombotic therapy in the primary and secondary prevention settings. […] In non-SLE individuals with aPL and no previous thrombosis, low-dose aspirin was given a 2C recommendation (based on low or very low quality evidence) for use in those with a high-risk aPL profile, especially in the presence of additional thrombotic risk factors. […] In patients with SLE and aPL (positive LA, isolated persistent aCL at medium-high titers), primary thromboprophylaxis with hydroxychloroquine and low-dose aspirin is recommended. […] The rates of VTE recurrence in patients with APS have generally exceeded bleeding risk associated with anticoagulant use, resulting in the recommendation from a number of guideline panels to consider long-term anticoagulation in patients with thrombosis and APS. […] In patients with APS, prevention of a recurrent thrombotic event (secondary prevention) is critical.

• #19 EULAR recommendations for the management of antiphospholipid syndrome in adults | Annals of the Rheumatic Diseases

  https://ard.bmj.com/content/78/10/1296

  In asymptomatic aPL carriers (not fulfilling any vascular or obstetric APS classification criteria) with a high-risk aPL profile with or without traditional risk factors, prophylactic treatment with low-dose aspirin (LDA) (75-100 mg daily) is recommended. […] Treatment with LDA for patients with SLE and high-risk aPL profile is supported by a subanalysis of eight studies, mostly observational, in a meta-analysis. […] In patients with definite APS and first venous thrombosis: Treatment with VKA with a target INR 2-3 is recommended. […] Rivaroxaban should not be used in patients with triple aPL positivity due to the high risk of recurrent events. […] In women with a high-risk aPL profile but no history of thrombosis or pregnancy complications (with or without SLE), treatment with LDA (75-100 mg/day) during pregnancy should be considered. […] In women with a history of obstetric APS only (no prior thrombotic events), with or without SLE: combination treatment with LDA and heparin at prophylactic dosage during pregnancy is recommended.

• #20 Antiphospholipid Syndrome and Its Management

  https://www.uspharmacist.com/article/antiphospholipid-syndrome-and-its-management

  Further research is needed in the form of randomized, controlled trials studying the potential role of LDA or other antiplatelet agents for primary prevention of thrombosis in asymptomatic aPL-positive patients. […] Long-term anticoagulation is recommended in most patients who have persistent aPLs and who had an otherwise unprovoked VTE. […] EULAR guidelines recommend an INR goal of 2 to 3 for patients with APS and unprovoked venous thrombosis. […] The 16th International Congress on Antiphospholipid Antibodies report found insufficient evidence for strong recommendations concerning the use of LDA for secondary prevention following a first APS-related arterial thrombosis; however, it stated that LDA use could be considered in combination with standard-intensity VKA therapy (INR goal, 2-3).

• #21 Antiphospholipid Syndrome (APS) – An Update on Clinical Features and Treatment Options

  https://openurologyandnephrologyjournal.com/VOLUME/8/PAGE/27/FULLTEXT/

  In the Antiphospholipid Antibody Acetylsalicylic Acid (APLASA) trial, aspirin 81 mg daily (considered low dose) did not show a benefit in the primary prophylaxis of APS. […] However, a meta-analysis of 11 observational and interventional studies suggested that the risk of first thrombotic event is significantly decreased by low dose aspirin among asymptomatic aPL individuals, patients with SLE or obstetric APS. […] The recommendation for first venous thrombosis is anticoagulation with a target INR of 2-3. […] However, if the thrombosis was unprovoked or the patient has a high risk profile as defined as triple APL antibody positive, persistent APL antibody positive, lupus anticoagulant positive, or high titer IgG of anti cardiolipin (aCL) or anti B2Glycoprotein (B2GPI) antibodies, lifelong anticoagulation is recommended.

• #22 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9741036/

  Due to the high risk of venous and arterial thrombosis associated with the use of combined oral contraceptives in young women, their use should be avoided in patients with triple positive aPLA. […] In patients with a high-risk aPLA profile and no history of thrombosis or obstetrical complications, prophylaxis with LDA is suggested, although with low evidence. […] Pregnant women with a history of thrombotic APS should be treated with LDA associated with LMWH at therapeutic doses. […] It has been proposed that women with a history of obstetric APS can receive an antithrombotic prophylaxis with variable intensity according to the type of pregnancy complications. […] In general, patients with APS have indication to continue lifelong anticoagulant treatment because of the high risk of recurrent thrombosis.

• #23 Patient education: Antiphospholipid syndrome (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/antiphospholipid-syndrome-beyond-the-basics

  The longer it takes the blood to clot, the higher the PT and INR. The target INR range depends upon the clinical situation. In most cases, the target range is 2 to 3. If the INR is below the target range (ie, under-anticoagulated), there is a risk of clotting. If, on the other hand, the INR is above the target range (ie, over-anticoagulated), there is an increased risk of bleeding. […] Antiplatelet treatments — Aspirin is another medication sometimes recommended for people with APS. Aspirin inhibits the clumping of platelets; platelets are tiny cell fragments in the blood that have a role in blood clotting. Under normal circumstances, platelets clump together and help form blood clots to stop bleeding when needed. […] Aspirin is sometimes used in addition to warfarin. It is not usually used as a replacement for warfarin, especially in people with a history of serious and recurrent blood clots.

• #24 Antiphospholipid Syndrome (APS) – An Update on Clinical Features and Treatment Options

  https://openurologyandnephrologyjournal.com/VOLUME/8/PAGE/27/FULLTEXT/

  The recommendation for arterial thrombosis or recurrent venous thrombosis with definite APS is high intensity anticoagulation (INR 3) or the combination of an antiplatelet agent with low intensity (INR 2-3) anticoagulation. […] The evidence suggests that the mortality due to bleeding with high intensity anticoagulation in recurrent thrombosis is much lower compared to the risk due to thrombosis. […] The goals of therapy in CAPS are to treat any precipitating factors, treat any on-going thrombotic events and suppress the cytokine storm. […] The common precipitating factors for CAPS include infections (respiratory, skin, urinary tract, and sepsis), surgical procedures, malignancy, lupus flares, sudden anticoagulation withdrawal, oral contraceptives and obstetric complications. […] The evidence supporting the therapeutic options is very limited due to lack of prospective trials.

• #25 Antiphospholipid Syndrome and Its Management

  https://www.uspharmacist.com/article/antiphospholipid-syndrome-and-its-management

  EULAR guidelines recommend VKA therapy after the first arterial thrombosis in APS patients, with a recommended INR goal of 2 to 3 or 3 to 4 based on the patients risk for bleeding and recurrent thrombosis; the guidelines add that treatment with a VKA (INR goal, 2-3) plus LDA may be considered. […] Further research is needed in the form of randomized, controlled trials to define the role of LDA or other antiplatelet agents, in combination with anticoagulation, in thrombotic APS patients. […] The 16th International Congress on Antiphospholipid Antibodies report recommends first-line therapy with a VKA in most patients. […] EULAR guidelines recommend against using rivaroxaban in patients with triple aPL positivity due to the high risk of recurrent events; however, they note that DOACs may be considered in certain patients, such as those with contraindications to VKAs or those unable to achieve target INR while on a VKA despite adherence.

• #26 Risk Assessment & Treatment in Antiphospholipid Syndrome Patients – The Rheumatologist

  https://www.the-rheumatologist.org/article/risk-assessment-treatment-in-antiphospholipid-syndrome-patients/

  Our recommendation at this point is to [prescribe] low-dose aspirin [for] patients who have a high-risk profilesay theyre triple positive or [have] a very strong lupus anticoagulant [with or without the] presence of other thrombotic risk factors, Dr. Sammaritano said. […] If I have patients with obstetric APS, especially who have a high-risk profile, I routinely suggest they continue low-dose aspirin, she said. […] For secondary prevention of unprovoked venous thrombosis, she recommends lifelong warfarin, with a moderate goal of a 2.0 to 3.0 international normalized ratio. […] To prevent recurrent arterial thromboses, the most telling data come from a Japanese study of 20 patients from a cohort that fits the profile of a patient most clinicians will likely see. […] Her recommendation for these patients is lifelong warfarin with an international normalized ratio goal of 3.0 to 4.0, or low-dose aspirin with a moderate warfarin goal of a 2.0 to 3.0 international normalized ratio.

• #27 EULAR recommendations for the management of antiphospholipid syndrome in adults | Annals of the Rheumatic Diseases

  https://ard.bmj.com/content/78/10/1296

  In asymptomatic aPL carriers (not fulfilling any vascular or obstetric APS classification criteria) with a high-risk aPL profile with or without traditional risk factors, prophylactic treatment with low-dose aspirin (LDA) (75-100 mg daily) is recommended. […] Treatment with LDA for patients with SLE and high-risk aPL profile is supported by a subanalysis of eight studies, mostly observational, in a meta-analysis. […] In patients with definite APS and first venous thrombosis: Treatment with VKA with a target INR 2-3 is recommended. […] Rivaroxaban should not be used in patients with triple aPL positivity due to the high risk of recurrent events. […] In women with a high-risk aPL profile but no history of thrombosis or pregnancy complications (with or without SLE), treatment with LDA (75-100 mg/day) during pregnancy should be considered. […] In women with a history of obstetric APS only (no prior thrombotic events), with or without SLE: combination treatment with LDA and heparin at prophylactic dosage during pregnancy is recommended.

• #28 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9741036/

  More accurate risk-stratification models to identify patients at increased risk of recurrent thrombosis who may benefit from an intensification of the antithrombotic therapy are needed, always considering the consequent high risk of bleeding. […] In conclusion, current evidence and guidelines pronounce against the use of DOAC in APS patients with triple positivity or with arterial thrombosis. On the other hand, in patients with APS with VTE and a single or double aPLA positivity, DOAC can be considered on an individual basis.

• #29 Antiphospholipid Syndrome and Its Management

  https://www.uspharmacist.com/article/antiphospholipid-syndrome-and-its-management

  EULAR guidelines recommend VKA therapy after the first arterial thrombosis in APS patients, with a recommended INR goal of 2 to 3 or 3 to 4 based on the patients risk for bleeding and recurrent thrombosis; the guidelines add that treatment with a VKA (INR goal, 2-3) plus LDA may be considered. […] Further research is needed in the form of randomized, controlled trials to define the role of LDA or other antiplatelet agents, in combination with anticoagulation, in thrombotic APS patients. […] The 16th International Congress on Antiphospholipid Antibodies report recommends first-line therapy with a VKA in most patients. […] EULAR guidelines recommend against using rivaroxaban in patients with triple aPL positivity due to the high risk of recurrent events; however, they note that DOACs may be considered in certain patients, such as those with contraindications to VKAs or those unable to achieve target INR while on a VKA despite adherence.

• #30 Risk Assessment & Treatment in Antiphospholipid Syndrome Patients – The Rheumatologist

  https://www.the-rheumatologist.org/article/risk-assessment-treatment-in-antiphospholipid-syndrome-patients/

  I do not recommend changing to a direct oral anticoagulant at this time for our patients with APS, she said. […] For treatment of APS in pregnancy, Dr. Sammaritanos main message was to use low-dose aspirin in combination with low-dose heparin, usually enoxaparin, when there is more risk involved for the patient.

• #31 Patient education: Antiphospholipid syndrome (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/antiphospholipid-syndrome-beyond-the-basics

  Pregnant people with antiphospholipid syndrome (APS) have an increased risk of developing a thrombosis (blood clot in a vein or artery) and of having a miscarriage compared with pregnant people without APS. They may also be at risk for other pregnancy-related complications, including preeclampsia and decreased blood flow to the fetus resulting in intrauterine growth restriction. […] Several treatments are available to reduce these risks. Treatment depends upon the person’s history of blood clots, miscarriage, stillbirth, and preeclampsia, as well as current antibody levels. For people who have antiphospholipid antibodies (aPL) but no history of blood clots or miscarriage, treatment may or may not be recommended. […] The following is a general description of available treatments. […] Aspirin — Low-dose aspirin may be used for pregnant people with APS in combination with heparin injections. Low-dose aspirin can be started before a person starts trying to get pregnant.

• #32

  https://www.nhs.uk/conditions/antiphospholipid-syndrome/

  Antiphospholipid syndrome (APS), sometimes known as Hughes syndrome, is a disorder of the immune system that causes an increased risk of blood clots. […] Although there’s no cure for APS, the risk of developing blood clots can be greatly reduced if it’s correctly diagnosed. […] An anticoagulant medicine, such as warfarin, or an antiplatelet, such as low-dose aspirin, is usually prescribed. […] Treatment with these medications can also improve a pregnant woman’s chance of having a successful pregnancy. […] With treatment, it’s estimated there’s about an 80% chance of having a successful pregnancy.

• #33 EULAR recommendations for the management of antiphospholipid syndrome in adults | Annals of the Rheumatic Diseases

  https://ard.bmj.com/content/78/10/1296

  In asymptomatic aPL carriers (not fulfilling any vascular or obstetric APS classification criteria) with a high-risk aPL profile with or without traditional risk factors, prophylactic treatment with low-dose aspirin (LDA) (75-100 mg daily) is recommended. […] Treatment with LDA for patients with SLE and high-risk aPL profile is supported by a subanalysis of eight studies, mostly observational, in a meta-analysis. […] In patients with definite APS and first venous thrombosis: Treatment with VKA with a target INR 2-3 is recommended. […] Rivaroxaban should not be used in patients with triple aPL positivity due to the high risk of recurrent events. […] In women with a high-risk aPL profile but no history of thrombosis or pregnancy complications (with or without SLE), treatment with LDA (75-100 mg/day) during pregnancy should be considered. […] In women with a history of obstetric APS only (no prior thrombotic events), with or without SLE: combination treatment with LDA and heparin at prophylactic dosage during pregnancy is recommended.

• #34 :: JKMS :: Journal of Korean Medical Science

  https://jkms.org/DOIx.php?id=10.3346/jkms.2021.36.e24

  During pregnancy, heparin plus LDA is recommended. […] Most importantly, a tailored approach and patient-oriented treatment are mandatory. […] Primary thrombo-prophylaxis is generally not recommended for patients who are positive for aPL but have no history of thrombosis, as relatively little is known about the risk of the first thromboembolism and the protective effects of LDA or anticoagulants in this population. […] In high risk situations, such as during extended immobilization and during post-operation and postpartum periods, thrombo-prophylaxis reduced the risk of thrombosis in aPL carriers. […] Antepartum: It is unclear whether pregnant women with aPL but no history of the clinical features of APS are at increased risk for obstetric morbidity or thrombosis during pregnancy. […] The majority of the Advisory Board of the Tenth aPL Antibodies recommended that pregnant women positive for aPL be treated with LDA, and LDA is generally recommended during pregnancy or at the beginning of attempting pregnancy, especially in women at high risk of pre-eclampsia.

• #35 EULAR recommendations for the management of antiphospholipid syndrome in adults | Annals of the Rheumatic Diseases

  https://ard.bmj.com/content/78/10/1296

  In asymptomatic aPL carriers (not fulfilling any vascular or obstetric APS classification criteria) with a high-risk aPL profile with or without traditional risk factors, prophylactic treatment with low-dose aspirin (LDA) (75-100 mg daily) is recommended. […] Treatment with LDA for patients with SLE and high-risk aPL profile is supported by a subanalysis of eight studies, mostly observational, in a meta-analysis. […] In patients with definite APS and first venous thrombosis: Treatment with VKA with a target INR 2-3 is recommended. […] Rivaroxaban should not be used in patients with triple aPL positivity due to the high risk of recurrent events. […] In women with a high-risk aPL profile but no history of thrombosis or pregnancy complications (with or without SLE), treatment with LDA (75-100 mg/day) during pregnancy should be considered. […] In women with a history of obstetric APS only (no prior thrombotic events), with or without SLE: combination treatment with LDA and heparin at prophylactic dosage during pregnancy is recommended.

• #36 Antiphospholipid Syndrome Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/333221-treatment

  For women with a history of APS and prior thrombosis, anticoagulation with therapeutic-dose low molecular weight heparin (LMWH) and low-dose aspirin is recommended. […] For women with a history of APS without thrombosis but with prior pregnancy loss, prophylactic-dose LMWH and low-dose aspirin are recommended. […] EULAR also recommends anticoagulation during pregnancy for patients with APS, with the drug and dose depending on individual risk profile. […] Unfortunately, current treatment fails to prevent complications in 20-30% of APS pregnancies. […] Retrospective clinical studies suggest that treatment with hydroxychloroquine may help prevent pregnancy complications in women with aPL and APS, and this strategy is currently being studied in a randomized controlled multicenter trial (HYPATIA).

• #37 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://www.mdpi.com/2077-0383/11/23/6984

  In patients with a high-risk aPLA profile and no history of thrombosis or obstetrical complications, prophylaxis with LDA is suggested, although with low evidence. […] Pregnant women with a history of thrombotic APS should be treated with LDA associated with LMWH at therapeutic doses. […] In case of ≥3 spontaneous miscarriages or ≥3 fetal loss, LDA and heparin at prophylactic doses are recommended; in case of delivery <34 weeks of gestation for eclampsia, severe pre-eclampsia, or placental insufficiency LDA or LDA with heparin at prophylactic dose is suggested. [...] In women with recurrent obstetrical complications despite LDA and heparin at prophylactic doses, intensification to therapeutic heparin is suggested and, in selected cases, addition of hydroxychloroquine, steroids or intravenous immunoglobulin may be considered.

• #38 :: JKMS :: Journal of Korean Medical Science

  https://jkms.org/DOIx.php?id=10.3346/jkms.2021.36.e24

  Postpartum: There is at present no high-quality evidence for postpartum care in aPL-positive patients without a clinical history of APS. […] Thrombo-prophylaxis is recommended in high risk situations, with the puerperium being an established risk factor for venous thromboembolism (VTE) and the risk being highest during the first 6 weeks postpartum. […] Guidelines suggest that patients with a history of three or more consecutive miscarriages before the tenth week of gestation or one or more fetal deaths beyond the tenth week of gestation be treated with LDA and a prophylactic dose of LMWH for 6 weeks after delivery, regardless of the route of delivery. […] In patients with obstetric APS, LDA is recommend before pregnancy and LDA plus a prophylactic dose of LMWH during pregnancy and for 6 weeks after delivery.

• #39 :: JKMS :: Journal of Korean Medical Science

  https://jkms.org/DOIx.php?id=10.3346/jkms.2021.36.e24

  In patients with a history of premature birth due to uteroplacental insufficiency but no history of fetal loss, LDA alone is acceptable. […] Women of childbearing age with vascular APS should be treated with warfarin with frequent pregnancy tests. […] The treatment of APS in women of childbearing age depends on the types of prior obstetric and/or vascular complications. […] Current review has limitations. First, it did not address extra criteria clinical manifestations in the diagnosis of APS. […] However, there are not enough data to judge the safety of DOACs during pregnancy.

• #40 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://www.mdpi.com/2077-0383/11/23/6984

  In patients with a high-risk aPLA profile and no history of thrombosis or obstetrical complications, prophylaxis with LDA is suggested, although with low evidence. […] Pregnant women with a history of thrombotic APS should be treated with LDA associated with LMWH at therapeutic doses. […] In case of ≥3 spontaneous miscarriages or ≥3 fetal loss, LDA and heparin at prophylactic doses are recommended; in case of delivery <34 weeks of gestation for eclampsia, severe pre-eclampsia, or placental insufficiency LDA or LDA with heparin at prophylactic dose is suggested. [...] In women with recurrent obstetrical complications despite LDA and heparin at prophylactic doses, intensification to therapeutic heparin is suggested and, in selected cases, addition of hydroxychloroquine, steroids or intravenous immunoglobulin may be considered.

• #41 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://www.mdpi.com/2077-0383/11/23/6984

  In patients with a high-risk aPLA profile and no history of thrombosis or obstetrical complications, prophylaxis with LDA is suggested, although with low evidence. […] Pregnant women with a history of thrombotic APS should be treated with LDA associated with LMWH at therapeutic doses. […] In case of ≥3 spontaneous miscarriages or ≥3 fetal loss, LDA and heparin at prophylactic doses are recommended; in case of delivery <34 weeks of gestation for eclampsia, severe pre-eclampsia, or placental insufficiency LDA or LDA with heparin at prophylactic dose is suggested. [...] In women with recurrent obstetrical complications despite LDA and heparin at prophylactic doses, intensification to therapeutic heparin is suggested and, in selected cases, addition of hydroxychloroquine, steroids or intravenous immunoglobulin may be considered.

• #42 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://www.mdpi.com/2077-0383/11/23/6984

  In patients with a high-risk aPLA profile and no history of thrombosis or obstetrical complications, prophylaxis with LDA is suggested, although with low evidence. […] Pregnant women with a history of thrombotic APS should be treated with LDA associated with LMWH at therapeutic doses. […] In case of ≥3 spontaneous miscarriages or ≥3 fetal loss, LDA and heparin at prophylactic doses are recommended; in case of delivery <34 weeks of gestation for eclampsia, severe pre-eclampsia, or placental insufficiency LDA or LDA with heparin at prophylactic dose is suggested. [...] In women with recurrent obstetrical complications despite LDA and heparin at prophylactic doses, intensification to therapeutic heparin is suggested and, in selected cases, addition of hydroxychloroquine, steroids or intravenous immunoglobulin may be considered.

• #43 Antiphospholipid Syndrome Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/333221-treatment

  For women with a history of APS and prior thrombosis, anticoagulation with therapeutic-dose low molecular weight heparin (LMWH) and low-dose aspirin is recommended. […] For women with a history of APS without thrombosis but with prior pregnancy loss, prophylactic-dose LMWH and low-dose aspirin are recommended. […] EULAR also recommends anticoagulation during pregnancy for patients with APS, with the drug and dose depending on individual risk profile. […] Unfortunately, current treatment fails to prevent complications in 20-30% of APS pregnancies. […] Retrospective clinical studies suggest that treatment with hydroxychloroquine may help prevent pregnancy complications in women with aPL and APS, and this strategy is currently being studied in a randomized controlled multicenter trial (HYPATIA).

• #44 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://www.mdpi.com/2077-0383/11/23/6984

  In patients with a high-risk aPLA profile and no history of thrombosis or obstetrical complications, prophylaxis with LDA is suggested, although with low evidence. […] Pregnant women with a history of thrombotic APS should be treated with LDA associated with LMWH at therapeutic doses. […] In case of ≥3 spontaneous miscarriages or ≥3 fetal loss, LDA and heparin at prophylactic doses are recommended; in case of delivery <34 weeks of gestation for eclampsia, severe pre-eclampsia, or placental insufficiency LDA or LDA with heparin at prophylactic dose is suggested. [...] In women with recurrent obstetrical complications despite LDA and heparin at prophylactic doses, intensification to therapeutic heparin is suggested and, in selected cases, addition of hydroxychloroquine, steroids or intravenous immunoglobulin may be considered.

• #45 Patient education: Antiphospholipid syndrome (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/antiphospholipid-syndrome-beyond-the-basics

  Heparin — Heparin must be given as an injection, either under the skin or into a vein. Most pregnant people who use heparin are taught to give their own injections into the skin. […] There are two types of heparin: unfractionated and low molecular weight heparin (LMWH). […] • Unfractionated heparin must be injected twice per day and has a risk of causing excessive bleeding, a low platelet count, and osteoporosis. […] • LMWH is usually injected once per day and has a lower risk of excessive bleeding, low platelet count, and bone thinning (osteoporosis) compared with unfractionated heparin. […] Heparin is usually started once pregnancy is confirmed and is usually stopped temporarily for planned procedures (eg, amniocentesis, cesarean section) and when labor begins. Either heparin or warfarin is recommended for six to eight weeks after delivery.

• #46 Patient education: Antiphospholipid syndrome (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/antiphospholipid-syndrome-beyond-the-basics

  Warfarin — Warfarin is not recommended for pregnant people with APS because of the potential risks to the developing fetus. Warfarin must be stopped before six weeks of pregnancy. […] Warfarin can be restarted after delivery and is often the preferred treatment for people with APS during the postpartum stage (the six to eight weeks following delivery). Warfarin is safe to take while breastfeeding. […] Preventing pregnancy — People with aPL (with or without APS) should not use birth control methods that contain estrogen because estrogen can increase the risk of developing a blood clot. A number of other methods of birth control are available, including progestin-only pills, an intrauterine device (IUD), condoms, a diaphragm, an injection (eg, Depo Provera), or a surgical procedure. These options are discussed separately.

• #47

  https://www.nhs.uk/conditions/antiphospholipid-syndrome/treatment/

  Treatment for antiphospholipid syndrome (APS) aims to reduce your risk of developing more blood clots. […] Most people with APS need to take anticoagulant or antiplatelet medication daily for the rest of their life. […] Women diagnosed with APS are strongly advised to plan for any future pregnancy. […] This is because treatment to improve the outcome of a pregnancy is most effective when it begins as soon as possible after an attempt to conceive. […] If you are sexually active you should use a reliable method of contraception. […] If you do want to have a baby, you should talk to the doctor in charge of your treatment for APS. […] If you’re diagnosed with APS, it’s important to take all possible steps to reduce your risk of developing blood clots. […] Effective ways of achieving this include: quit smoking, eating a healthy, balanced diet low in fat and sugar and containing plenty of fruit and vegetables, taking regular exercise, maintaining a healthy weight and losing weight if you’re obese (have a body mass index of 30 or more).

• #48 Preventing Clots in People With Antiphospholipid Antibodies

  https://www.hss.edu/conditions_blood-clots-antiphospholipid-antibody-positive-patients.asp

  Discuss with your doctor if your antiphospholipid antibody (aPL) profile is clinically significant (persistent versus transient aPL, lupus anticoagulant test positive versus negative, anticardiolipin or anti-2-Glycoprotein-I tests moderate-to-high positive versus low titer positive). […] Discuss with your doctor if you have an established diagnosis of antiphospholipid syndrome (symptomatic with history of blood clots) or you only have aPL positivity (non-symptomatic without clinical events). […] The optimal control of your systemic autoimmune disease activity is crucial. […] Smoking increases the risk of blood clots in aPL-positive patients. The solution is obvious: Avoid smoking and participate in smoking cessation counseling programs if you are a smoker. […] Discuss with your doctor whether other forms of contraception can be considered.

• #49 Antiphospholipid Syndrome: Symptoms, Diagnosis and Treatments

  https://www.webmd.com/dvt/what-is-antiphospholipid-syndrome

  Avoid estrogen therapy (such as for menopause symptoms or birth control), which also makes clotting more likely. […] If you’re diagnosed with APS, stop smoking, which harms your blood vessels and raises your risk for clots. […] Regular physical activity also helps reduce your risk of conditions such as diabetes and heart disease.

• #50 Lupus anticoagulants and antiphospholipid antibodies Information | Mount Sinai – New York

  https://www.mountsinai.org/health-library/diseases-conditions/lupus-anticoagulants-and-antiphospholipid-antibodies

  The treatment for APS is directed at preventing complications from new blood clots forming or existing clots getting larger. You will need to take some form of blood-thinning medicine. If you also have an autoimmune disease, such as lupus, you will need to keep that condition under control as well. […] Take the following steps to help prevent blood clots from forming: Avoid most birth control pills or hormone treatments for menopause (women). DO NOT smoke or use other tobacco products. Get up and move around during long plane flights or other times when you have to sit or lie down for extended periods. Move your ankles up and down when you can’t move around. […] You will be prescribed blood-thinning medicines (such as heparin and warfarin) to help prevent blood clots: After surgery, After a bone fracture, With active cancer, When you need to sit or lie down for long periods of time, such as during a hospital stay or recovering at home. […] You may also need to take blood thinners for 3 to 4 weeks after surgery to lower your risk for blood clots.

• #51 Antiphospholipid syndrome: Symptoms, treatment, and diagnosis

  https://www.medicalnewstoday.com/articles/181700

  A patient with APS needs to take all possible measures to lower the risk of developing blood clots. This includes: […] not smoking […] maintaining a healthy bodyweight […] remaining physically active.

• #52 Antiphospholipid Syndrome (APS Syndrome): Symptoms, Causes, Diagnosis, Treatment, and Prevention

  https://www.everydayhealth.com/antiphospholipid-syndrome/guide/

  Theres no cure for antiphospholipid syndrome, and its not possible to prevent the disorder. But by taking medication and making certain lifestyle changes, you can reduce the risk of blood clots. […] Engaging in regular exercise, eating a healthy diet, and practicing other health-promoting habits can reduce your risk of high blood pressure and diabetes, which can increase your risk for stroke. […] Your doctor may also advise you to take steps that would lower your risk of blood clots, which may include: Maintaining a healthy A1C level, if you have diabetes; Managing your blood pressure; Keeping your cholesterol levels down; Losing weight, if you have obesity; Stopping smoking; Avoiding estrogen therapy.

• #53

  https://www.nhs.uk/conditions/antiphospholipid-syndrome/treatment/

  Treatment for antiphospholipid syndrome (APS) aims to reduce your risk of developing more blood clots. […] Most people with APS need to take anticoagulant or antiplatelet medication daily for the rest of their life. […] Women diagnosed with APS are strongly advised to plan for any future pregnancy. […] This is because treatment to improve the outcome of a pregnancy is most effective when it begins as soon as possible after an attempt to conceive. […] If you are sexually active you should use a reliable method of contraception. […] If you do want to have a baby, you should talk to the doctor in charge of your treatment for APS. […] If you’re diagnosed with APS, it’s important to take all possible steps to reduce your risk of developing blood clots. […] Effective ways of achieving this include: quit smoking, eating a healthy, balanced diet low in fat and sugar and containing plenty of fruit and vegetables, taking regular exercise, maintaining a healthy weight and losing weight if you’re obese (have a body mass index of 30 or more).

• #54 Preventing Clots in People With Antiphospholipid Antibodies

  https://www.hss.edu/conditions_blood-clots-antiphospholipid-antibody-positive-patients.asp

  Discuss with your doctor about the aggressive management of these conditions, exercise regularly, and eat sensibly. […] Convey your aPL-positivity to your physicians involved in your surgeries so that they can take additional blood clot prevention measures before and after your surgery. […] It is recommended to walk at least every hour when traveling. Drink plenty of water and limit your alcohol intake. […] You should always speak with your doctor about your risks of cardiovascular disease and about preventive medications or lifestyle changes that can decrease your chances of cardiovascular disease specific to your needs.

• #55 Antiphospholipid Syndrome: The Risk of Travel at High Altitudes – The Rheumatologist

  https://www.the-rheumatologist.org/article/antiphospholipid-syndrome-the-risk-of-travel-at-high-altitudes/?singlepage=1&theme=print-friendly

  Guidelines specific to APS, travel long-haul flights are lacking. The protective effect of low dose aspirin in individuals with clinically significant aPLA values is not supported by randomized controlled data. […] It is prudent for practitioners to consider anticoagulation for high-risk patients with APS who are traveling for long distances or at high altitudes. When deciding whether to anticoagulate a patient positive for aPLA, it is important to be attentive of clinically significant laboratory values, as well as comorbidities associated with a greater increase in the risk of clotting. Further, in individuals with known APS, consideration for a booster dose of enoxaparin (1 mg/kg) is not unreasonable two to four hours prior to travel on flights exceeding eight hours duration. Although our recommendations are based on a review of the literature, further research is encouraged for patients with APS to assist in preventive measures and overall improved quality of life.

• #56 APS | APS Foundation of America, Inc.

  https://apsfa.org/aps/

  Expert care and close monitoring of the pregnancy is essential by a doctor knowledgeable about APS. During pregnancy, physicians may recommend low doses of aspirin and daily injections of the blood thinning drug, heparin. […] Over the long term, many doctors recommend women continue to take a low dose of aspirin to reduce the risk of developing dangerous blood clots. […] Women also need to avoid estrogen therapy (such as birth control or hormone replacement therapy) because estrogen predisposes patients to clotting. […] Some women taking warfarin experience problems with increased bleeding. It can lead to anemia. Tell your doctor about this problem. The doctor can recommend several options and prevent anemia. […] Long trips, especially by air, have some clotting risk even for non-APS people. It is important for people with APS to get up and walk around at least every couple of hours.

• #57 Antiphospholipid Syndrome: The Risk of Travel at High Altitudes – The Rheumatologist

  https://www.the-rheumatologist.org/article/antiphospholipid-syndrome-the-risk-of-travel-at-high-altitudes/?singlepage=1&theme=print-friendly

  Guidelines specific to APS, travel long-haul flights are lacking. The protective effect of low dose aspirin in individuals with clinically significant aPLA values is not supported by randomized controlled data. […] It is prudent for practitioners to consider anticoagulation for high-risk patients with APS who are traveling for long distances or at high altitudes. When deciding whether to anticoagulate a patient positive for aPLA, it is important to be attentive of clinically significant laboratory values, as well as comorbidities associated with a greater increase in the risk of clotting. Further, in individuals with known APS, consideration for a booster dose of enoxaparin (1 mg/kg) is not unreasonable two to four hours prior to travel on flights exceeding eight hours duration. Although our recommendations are based on a review of the literature, further research is encouraged for patients with APS to assist in preventive measures and overall improved quality of life.

• #58 Preventing Clots in People With Antiphospholipid Antibodies

  https://www.hss.edu/conditions_blood-clots-antiphospholipid-antibody-positive-patients.asp

  Discuss with your doctor about the aggressive management of these conditions, exercise regularly, and eat sensibly. […] Convey your aPL-positivity to your physicians involved in your surgeries so that they can take additional blood clot prevention measures before and after your surgery. […] It is recommended to walk at least every hour when traveling. Drink plenty of water and limit your alcohol intake. […] You should always speak with your doctor about your risks of cardiovascular disease and about preventive medications or lifestyle changes that can decrease your chances of cardiovascular disease specific to your needs.

• #59 Antiphospholipid Syndrome: The Risk of Travel at High Altitudes – The Rheumatologist

  https://www.the-rheumatologist.org/article/antiphospholipid-syndrome-the-risk-of-travel-at-high-altitudes/?singlepage=1&theme=print-friendly

  Guidelines specific to APS, travel long-haul flights are lacking. The protective effect of low dose aspirin in individuals with clinically significant aPLA values is not supported by randomized controlled data. […] It is prudent for practitioners to consider anticoagulation for high-risk patients with APS who are traveling for long distances or at high altitudes. When deciding whether to anticoagulate a patient positive for aPLA, it is important to be attentive of clinically significant laboratory values, as well as comorbidities associated with a greater increase in the risk of clotting. Further, in individuals with known APS, consideration for a booster dose of enoxaparin (1 mg/kg) is not unreasonable two to four hours prior to travel on flights exceeding eight hours duration. Although our recommendations are based on a review of the literature, further research is encouraged for patients with APS to assist in preventive measures and overall improved quality of life.

• #60 Patient education: Antiphospholipid syndrome (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/antiphospholipid-syndrome-beyond-the-basics

  Treatment before and during surgery — Anticoagulant and antiplatelet treatments may need to be adjusted before, during, and after surgery or other procedures that have a risk of bleeding. The goal of treatment adjustments is to minimize the risk of new blood clots as well as the risk of excessive bleeding. This usually involves stopping warfarin several days before surgery. […] The person may be given heparin before and after surgery, depending upon several factors (the person’s previous history of blood clots, type of surgery, etc). Warfarin can usually be restarted within 12 hours after surgery. A person should speak with the provider who prescribes their warfarin to determine the best treatment regimen (and the timing) before and after surgery. […] ANTIPHOSPHOLIPID SYNDROME AND PREGNANCY

• #61 Lupus anticoagulants and antiphospholipid antibodies Information | Mount Sinai – New York

  https://www.mountsinai.org/health-library/diseases-conditions/lupus-anticoagulants-and-antiphospholipid-antibodies

  The treatment for APS is directed at preventing complications from new blood clots forming or existing clots getting larger. You will need to take some form of blood-thinning medicine. If you also have an autoimmune disease, such as lupus, you will need to keep that condition under control as well. […] Take the following steps to help prevent blood clots from forming: Avoid most birth control pills or hormone treatments for menopause (women). DO NOT smoke or use other tobacco products. Get up and move around during long plane flights or other times when you have to sit or lie down for extended periods. Move your ankles up and down when you can’t move around. […] You will be prescribed blood-thinning medicines (such as heparin and warfarin) to help prevent blood clots: After surgery, After a bone fracture, With active cancer, When you need to sit or lie down for long periods of time, such as during a hospital stay or recovering at home. […] You may also need to take blood thinners for 3 to 4 weeks after surgery to lower your risk for blood clots.

• #62 Lupus anticoagulants and antiphospholipid antibodies Information | Mount Sinai – New York

  https://www.mountsinai.org/health-library/diseases-conditions/lupus-anticoagulants-and-antiphospholipid-antibodies

  The treatment for APS is directed at preventing complications from new blood clots forming or existing clots getting larger. You will need to take some form of blood-thinning medicine. If you also have an autoimmune disease, such as lupus, you will need to keep that condition under control as well. […] Take the following steps to help prevent blood clots from forming: Avoid most birth control pills or hormone treatments for menopause (women). DO NOT smoke or use other tobacco products. Get up and move around during long plane flights or other times when you have to sit or lie down for extended periods. Move your ankles up and down when you can’t move around. […] You will be prescribed blood-thinning medicines (such as heparin and warfarin) to help prevent blood clots: After surgery, After a bone fracture, With active cancer, When you need to sit or lie down for long periods of time, such as during a hospital stay or recovering at home. […] You may also need to take blood thinners for 3 to 4 weeks after surgery to lower your risk for blood clots.

• #63 Current concepts in the diagnosis and management of antiphospholipid syndrome and ocular manifestations | Journal of Ophthalmic Inflammation and Infection | Full Text

  https://joii-journal.springeropen.com/articles/10.1186/s12348-021-00240-8

  Prevention of aPL-induced coagulation is the main goal in the treatment of thrombotic events in APS. […] Life-long anticoagulation is essential in APS patients who have thrombotic event history. […] Regarding APS associated with pure ophthalmic manifestations however, there are no current guidelines nor any therapeutic actions suggested other than for preventing subsequent events. […] Furthermore, systemic anticoagulation, particularly with warfarin, has been linked to increased risk of subsequent retinal vein and arterial occlusion, even at therapeutic dosages. […] Hydroxychloroquine (HCQ) is an antimalarial drug that is typically used in SLE patients which has anti-inflammatory as well as anti-thrombotic effects. […] On the basis of anti-thrombotic and immunomodulatory properties, HCQ can be considered as an adjunctive therapy for APS patients who have recurrent thrombotic events despite being on adequate anticoagulation therapy.

• #64 Current concepts in the diagnosis and management of antiphospholipid syndrome and ocular manifestations | Journal of Ophthalmic Inflammation and Infection | Full Text

  https://joii-journal.springeropen.com/articles/10.1186/s12348-021-00240-8

  Prevention of aPL-induced coagulation is the main goal in the treatment of thrombotic events in APS. […] Life-long anticoagulation is essential in APS patients who have thrombotic event history. […] Regarding APS associated with pure ophthalmic manifestations however, there are no current guidelines nor any therapeutic actions suggested other than for preventing subsequent events. […] Furthermore, systemic anticoagulation, particularly with warfarin, has been linked to increased risk of subsequent retinal vein and arterial occlusion, even at therapeutic dosages. […] Hydroxychloroquine (HCQ) is an antimalarial drug that is typically used in SLE patients which has anti-inflammatory as well as anti-thrombotic effects. […] On the basis of anti-thrombotic and immunomodulatory properties, HCQ can be considered as an adjunctive therapy for APS patients who have recurrent thrombotic events despite being on adequate anticoagulation therapy.

• #65 Antiphospholipid Syndrome Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/333221-treatment

  For women with a history of APS and prior thrombosis, anticoagulation with therapeutic-dose low molecular weight heparin (LMWH) and low-dose aspirin is recommended. […] For women with a history of APS without thrombosis but with prior pregnancy loss, prophylactic-dose LMWH and low-dose aspirin are recommended. […] EULAR also recommends anticoagulation during pregnancy for patients with APS, with the drug and dose depending on individual risk profile. […] Unfortunately, current treatment fails to prevent complications in 20-30% of APS pregnancies. […] Retrospective clinical studies suggest that treatment with hydroxychloroquine may help prevent pregnancy complications in women with aPL and APS, and this strategy is currently being studied in a randomized controlled multicenter trial (HYPATIA).

• #66 Current concepts in the diagnosis and management of antiphospholipid syndrome and ocular manifestations | Journal of Ophthalmic Inflammation and Infection | Full Text

  https://joii-journal.springeropen.com/articles/10.1186/s12348-021-00240-8

  Statins have demonstrated anti-thrombotic and anti-inflammatory properties such as inhibition of tissue factor production in endothelial cells and prevention of anti-2GPI antibody-mediated endothelial adherence. […] Eculizumab has been used in treatment of refractory CAPS and aPL-mediated acute thrombotic microangiopathy after renal transplantations. […] Inhibition of mammalian target of rapamycin (mTOR) pathway can prevent APS-related vasculopathy by inhibiting proliferation of endothelial and vascular smooth muscle cells. […] Based on these findings, mTOR inhibition can be considered as a useful therapeutic option in the future in terms of preventing aPL-mediated thrombosis and inflammation in APS patients. […] Although anticoagulation therapy is still the standard treatment method in the management of APS, better understanding of the mechanism and identifying more specific tools in the pathogenesis of APS may provide target-specific therapy and better control of disease in patients who are refractory to standard therapy.

• #67 Antiphospholipid Syndrome and Its Management

  https://www.uspharmacist.com/article/antiphospholipid-syndrome-and-its-management

  Future research is needed on the potential role of DOACs in APS. Studies should take into account APSs heterogeneity and the fact that thrombotic risk is influenced by the clinical and laboratory APS phenotype. […] The 16th International Congress on Antiphospholipid Antibodies report notes that the addition of HCQ may be considered adjunctively to antithrombotic treatment in patients with anticoagulant-refractory APS. […] EULAR guidelines state that HCQ may be used in women with refractory obstetric APS. […] The report adds that statins may be considered adjunctively to antithrombotic treatment in anticoagulant-refractory thrombotic APS patients. […] EULAR guidelines call for more research on the role of HCQ in primary thrombosis prevention. […] The 16th International Congress on Antiphospholipid Antibodies report recommends correcting vitamin D deficiency and insufficiency in all patients based on guidelines for the general population.

• #68 Patient education: Antiphospholipid syndrome (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/antiphospholipid-syndrome-beyond-the-basics

  Warfarin — Warfarin is not recommended for pregnant people with APS because of the potential risks to the developing fetus. Warfarin must be stopped before six weeks of pregnancy. […] Warfarin can be restarted after delivery and is often the preferred treatment for people with APS during the postpartum stage (the six to eight weeks following delivery). Warfarin is safe to take while breastfeeding. […] Preventing pregnancy — People with aPL (with or without APS) should not use birth control methods that contain estrogen because estrogen can increase the risk of developing a blood clot. A number of other methods of birth control are available, including progestin-only pills, an intrauterine device (IUD), condoms, a diaphragm, an injection (eg, Depo Provera), or a surgical procedure. These options are discussed separately.

• #69 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://www.mdpi.com/2077-0383/11/23/6984

  Patients with aPLA have an increased risk not only of recurrent, but also of first thrombotic events, and primary prophylaxis is of pivotal importance. […] According to the most recent guidelines, primary antithrombotic prophylaxis with low dose (75–100 mg/day) aspirin (LDA) in high-risk profile aPLA patients without history of thrombosis is recommended. […] However, the use of low molecular weight heparin (LMWH) in high-risk situations such as postoperative periods, lower limb fracture, immobilization, hospitalization, pregnancy/puerperium or central venous catheter placement is widely accepted, as for all other severe thrombophilia abnormalities. […] Due to the high risk of venous and arterial thrombosis associated with the use of combined oral contraceptives in young women, their use should be avoided in patients with triple positive aPLA.

• #70 Antiphospholipid Syndrome: Symptoms, Diagnosis and Treatments

  https://www.webmd.com/dvt/what-is-antiphospholipid-syndrome

  Avoid estrogen therapy (such as for menopause symptoms or birth control), which also makes clotting more likely. […] If you’re diagnosed with APS, stop smoking, which harms your blood vessels and raises your risk for clots. […] Regular physical activity also helps reduce your risk of conditions such as diabetes and heart disease.

• #71 Patient education: Antiphospholipid syndrome (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/antiphospholipid-syndrome-beyond-the-basics

  Warfarin — Warfarin is not recommended for pregnant people with APS because of the potential risks to the developing fetus. Warfarin must be stopped before six weeks of pregnancy. […] Warfarin can be restarted after delivery and is often the preferred treatment for people with APS during the postpartum stage (the six to eight weeks following delivery). Warfarin is safe to take while breastfeeding. […] Preventing pregnancy — People with aPL (with or without APS) should not use birth control methods that contain estrogen because estrogen can increase the risk of developing a blood clot. A number of other methods of birth control are available, including progestin-only pills, an intrauterine device (IUD), condoms, a diaphragm, an injection (eg, Depo Provera), or a surgical procedure. These options are discussed separately.

• #72

  https://www.nhs.uk/conditions/antiphospholipid-syndrome/treatment/

  Treatment for antiphospholipid syndrome (APS) aims to reduce your risk of developing more blood clots. […] Most people with APS need to take anticoagulant or antiplatelet medication daily for the rest of their life. […] Women diagnosed with APS are strongly advised to plan for any future pregnancy. […] This is because treatment to improve the outcome of a pregnancy is most effective when it begins as soon as possible after an attempt to conceive. […] If you are sexually active you should use a reliable method of contraception. […] If you do want to have a baby, you should talk to the doctor in charge of your treatment for APS. […] If you’re diagnosed with APS, it’s important to take all possible steps to reduce your risk of developing blood clots. […] Effective ways of achieving this include: quit smoking, eating a healthy, balanced diet low in fat and sugar and containing plenty of fruit and vegetables, taking regular exercise, maintaining a healthy weight and losing weight if you’re obese (have a body mass index of 30 or more).

• #73 Antiphospholipid Syndrome (APS): Symptoms and Treatment

  https://patient.info/allergies-blood-immune/blood-clotting-tests/antiphospholipid-syndrome

  If you have APS it is really important that pregnancies should be planned. You should ensure safe contraception unless you are prepared for pregnancy. Consult your doctor when you are thinking about trying to have a baby. You may need to alter your medication or start medication before you start to try. […] If you are trying to have a baby and are on long-term warfarin, you should be switched to heparin. You can stay on heparin throughout pregnancy. […] The National Institute for Health and Care Excellence (NICE) recommends that women who have had a venous thromboembolism do not use hormone replacement therapy (HRT) to treat the menopause. However, transdermal HRT (that given through the skin, in a patch or gel) does not increase the risk of a future blood clot.

• #74 APS | APS Foundation of America, Inc.

  https://apsfa.org/aps/

  It is very important to take your medicine every day. Try to take your the medicine at the same time each day for consistency. […] If you test positive for APS Antibodies you should be aware of the symptoms caused by blood clots. If any of these symptoms occur, seek medical help immediately. […] APS treatment is life long. Treatment of blood clots caused by APS outweighs the small side effects by treatment.

• #75 Living With Antiphospholipid Antibody Syndrome | Hematology-Oncology Associates of CNY

  https://www.hoacny.com/patient-resources/blood-disorders/antiphospholipid-antibody-syndrome/living-antiphospholipid

  Antiphospholipid antibody syndrome (APS) has no cure. However, you can take steps to control the disorder and prevent complications. […] You may need to take anticoagulants, or „blood thinners,” to prevent blood clots or to keep them from getting larger. You should take these medicines exactly as your doctor prescribes. […] Women who have APS shouldn’t use birth control or hormone therapy that contains estrogen. Estrogen increases the risk of blood clots. Talk with your doctor about other options. […] If you have APS, getting regular medical checkups is important. Have blood tests done as your doctor directs. These tests help track how well your blood is clotting. […] APS medicines might increase your risk of bleeding. Thus, your doctor may advise you to avoid activities that have a high risk of injury, such as some contact sports. […] Talk with your doctor about how to manage your APS if you’re pregnant or planning a pregnancy.

• #76 Management of Antiphospholipid Syndrome

  https://www.mdpi.com/2227-9059/8/11/508

  The decision of primary prophylaxis should be taken after a patient-centred risk stratification, which includes aPL profile (number, titer, isotype), coexistence of other auto-immune disease or an inherited thrombophilia, and cardiovascular risk factors. […] EULAR recommends primary prophylaxis with LDA (75–100 mg/day) in asymptomatic aPL carriers in the following circumstances: (1) high-risk aPL profile with or without traditional risk factors, (2) patients with SLE and high-risk aPL profile, and (3) non-pregnant women with a history of obstetric APS only. […] In summary, the management of APS should be patient centred, taking into account risk stratification, clinical phenotype, and comorbidities.

• #77 Antiphospholipid Syndrome: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/333221-overview

  In general, treatment regimens for APS must be individualized according to the patient’s current clinical status and history of thrombotic events. […] For patients with APS, prophylaxis is needed during surgery or hospitalization, as is management of any associated autoimmune disease. Low-dose aspirin is used widely in this setting; although its effectiveness remains unproven. […] For thrombosis, perform full anticoagulation with intravenous or subcutaneous heparin followed by warfarin therapy.

• #78 Anticoagulant Therapy in Patients with Antiphospholipid Syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9741036/

  More accurate risk-stratification models to identify patients at increased risk of recurrent thrombosis who may benefit from an intensification of the antithrombotic therapy are needed, always considering the consequent high risk of bleeding. […] In conclusion, current evidence and guidelines pronounce against the use of DOAC in APS patients with triple positivity or with arterial thrombosis. On the other hand, in patients with APS with VTE and a single or double aPLA positivity, DOAC can be considered on an individual basis.

• #79 EULAR recommendations for the management of antiphospholipid syndrome in adults | Annals of the Rheumatic Diseases

  https://ard.bmj.com/content/78/10/1296

  The objective was to develop evidence-based recommendations for the management of antiphospholipid syndrome (APS) in adults. […] Risk modification includes screening for and management of cardiovascular and venous thrombosis risk factors, patient education about treatment adherence, and lifestyle counselling. […] Low-dose aspirin (LDA) is recommended for asymptomatic aPL carriers, patients with systemic lupus erythematosus without prior thrombotic or obstetric APS, and non-pregnant women with a history of obstetric APS only, all with high-risk aPL profiles. […] In women with prior obstetric APS, combination treatment with LDA and prophylactic dosage heparin during pregnancy is recommended. […] These recommendations aim to guide treatment in adults with APS. High-quality evidence is limited, indicating a need for more research.

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