Antiphospholipid antibody syndrome

Section editor
	Benjamin Tillman, MD Vanderbilt University Nashville, TN

1 regimens on this page 1 variants on this page

Guidelines

Emerging data suggests the DOACs are inferior to VKAs in patients with APS. The trials are included here for reference, but most do not recommend these agents for APS. Due to the paucity of trials in this particular condition, many seek guidance from the venous thromboembolism (VTE) literature.

All lines of therapy

Aspirin & Warfarin

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Regimen

Study	Evidence	Comparator	Efficacy
Okuma et al. 2009	Phase III (E-esc)	Aspirin	Lower cumulative incidence of ischemic stroke

Note: Small study of 20 patients. All meeting the 2006 Sydney criteria for APS in setting of an ischemic stroke.

Anticoagulation

• Warfarin (Coumadin) PO with INR goal 2.0 to 3.0
• Aspirin 100 mg PO once per day

Continued indefinitely

References

1. Okuma H, Kitagawa Y, Yasuda T, Tokuoka K, Takagi S. Comparison between single antiplatelet therapy and combination of antiplatelet and anticoagulation therapy for secondary prevention in ischemic stroke patients with antiphospholipid syndrome. Int J Med Sci. 2009 Dec 5;7(1):15-8. link to original article link to PMC article PubMed

Rituximab monotherapy

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Regimen

Study	Evidence	Efficacy
Erkan et al. 2013 (RITAPS)	Phase II	Some improvement in non-criteria manifestations of APS

Note: This small phase 2 study (19 patients) did not identify any significant change in the antiphospholipid antibody profiles of the enrolled patients, but it did observe some improvements in the non-criteria manifestations of APS. This included thrombocytopenia, cardiac valve disease, skin ulcer, aPL nephropathy, and cognitive dysfunction.

Immunosuppressive therapy

• Rituximab (Rituxan) 1000 mg IV once on day 1

14-day cycle for 2 cycles

References

1. RITAPS: Erkan D, Vega J, Ramon G, Kozora E, Lockshin MD. A pilot open-label phase II trial of rituximab for non-criteria manifestations of antiphospholipid syndrome. Arthritis Rheum. 2013 Feb;65(2):464-71. link to original article PubMed

Rivaroxaban monotherapy

Regimen

Study	Evidence	Comparator	Efficacy
Cohen et al. 2016 (RAPS)	Phase II/III (E-switch-ooc)	Warfarin	Inconclusive whether non-inferior % change in endogenous thrombin potential
Pengo et al. 2018 (TRAPS)	Phase III (E-switch-ooc)	Warfarin	Higher rate of events

Note: TRAPS was closed prematurely due to excess events in the rivaroxaban arm. Although we include here for historical context, this regimen should not be used outside of the context of a clinical trial.

Anticoagulation

• Rivaroxaban (Xarelto) PO 20 mg PO once per day

Continued indefinitely

References

1. RAPS: Cohen H, Hunt BJ, Efthymiou M, Arachchillage DR, Mackie IJ, Clawson S, Sylvestre Y, Machin SJ, Bertolaccini ML, Ruiz-Castellano M, Muirhead N, Doré CJ, Khamashta M, Isenberg DA; RAPS trial investigators. Rivaroxaban versus warfarin to treat patients with thrombotic antiphospholipid syndrome, with or without systemic lupus erythematosus (RAPS): a randomised, controlled, open-label, phase 2/3, non-inferiority trial. Lancet Haematol. 2016 Sep;3(9):e426-36. link to original article link to PMC article PubMed
2. TRAPS: Pengo V, Denas G, Zoppellaro G, Jose SP, Hoxha A, Ruffatti A, Andreoli L, Tincani A, Cenci C, Prisco D, Fierro T, Gresele P, Cafolla A, De Micheli V, Ghirarduzzi A, Tosetto A, Falanga A, Martinelli I, Testa S, Barcellona D, Gerosa M, Banzato A. Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood. 2018 Sep 27;132(13):1365-1371. Epub 2018 Jul 12. link to original article PubMed

Warfarin monotherapy

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Regimen

Study	Evidence	Comparator	Efficacy
Crowther et al. 2003	Phase III (C)	High-intensity Warfarin (INR 3.1 to 4.0)	Did not meet primary endpoint of recurrent VTE
Finazzi et al. 2005 (WAPS)	Phase III (C)	High-intensity Warfarin (INR 3.0 to 4.5)	Did not meet primary endpoint of recurrent symptomatic VTE
Cohen et al. 2016 (RAPS)	Phase II/III (C)	Rivaroxaban	Inconclusive whether non-inferior % change in endogenous thrombin potential
Pengo et al. 2018 (TRAPS)	Phase III (C)	Rivaroxaban	Fewer events
Ordi-Ros et al. 2019 (SAP-02)	Phase II/III (C)	Rivaroxaban	Inconclusive whether non-inferior new VTE

Note: TRAPS was closed prematurely due to excess events in the rivaroxaban arm.

Anticoagulation

• Warfarin (Coumadin) PO titrated to goal INR 2.0 to 3.0
  • Note: some trials specify a goal INR 2.5 without a range given

Continued indefinitely

References

1. Crowther MA, Ginsberg JS, Julian J, Denburg J, Hirsh J, Douketis J, Laskin C, Fortin P, Anderson D, Kearon C, Clarke A, Geerts W, Forgie M, Green D, Costantini L, Yacura W, Wilson S, Gent M, Kovacs MJ. A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome. N Engl J Med. 2003 Sep 18;349(12):1133-8. Erratum in: N Engl J Med. 2004 Jul 8;351(2):200. N Engl J Med. 2003 Dec 25;349(26):2577. link to original article PubMed
2. WAPS: Finazzi G, Marchioli R, Brancaccio V, Schinco P, Wisloff F, Musial J, Baudo F, Berrettini M, Testa S, D'Angelo A, Tognoni G, Barbui T. A randomized clinical trial of high-intensity warfarin vs conventional antithrombotic therapy for the prevention of recurrent thrombosis in patients with the antiphospholipid syndrome (WAPS). J Thromb Haemost. 2005 May;3(5):848-53. link to original article PubMed
3. RAPS: Cohen H, Hunt BJ, Efthymiou M, Arachchillage DR, Mackie IJ, Clawson S, Sylvestre Y, Machin SJ, Bertolaccini ML, Ruiz-Castellano M, Muirhead N, Doré CJ, Khamashta M, Isenberg DA; RAPS trial investigators. Rivaroxaban versus warfarin to treat patients with thrombotic antiphospholipid syndrome, with or without systemic lupus erythematosus (RAPS): a randomised, controlled, open-label, phase 2/3, non-inferiority trial. Lancet Haematol. 2016 Sep;3(9):e426-36. link to original article link to PMC article PubMed
4. TRAPS: Pengo V, Denas G, Zoppellaro G, Jose SP, Hoxha A, Ruffatti A, Andreoli L, Tincani A, Cenci C, Prisco D, Fierro T, Gresele P, Cafolla A, De Micheli V, Ghirarduzzi A, Tosetto A, Falanga A, Martinelli I, Testa S, Barcellona D, Gerosa M, Banzato A. Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood. 2018 Sep 27;132(13):1365-1371. Epub 2018 Jul 12. link to original article PubMed
5. SAP-02: Ordi-Ros J, Sáez-Comet L, Pérez-Conesa M, Vidal X, Riera-Mestre A, Castro-Salomó A, Cuquet-Pedragosa J, Ortiz-Santamaria V, Mauri-Plana M, Solé C, Cortés-Hernández J. Rivaroxaban versus vitamin K antagonist in antiphospholipid syndrome: a randomized noninferiority trial. Ann Intern Med. 2019 Oct 15. [Epub ahead of print] link to original article PubMed