Thrombosis determines intensity of lifelong anticoagulation Tx
The mainstay of therapy for patients with APS is lifelong anticoagulation with a vitamin K antagonist. The intensity of anticoagulation is determined based on the presence of venous or arterial thrombosis. In patients who present with arterial thrombosis, a higher intensity vitamin K antagonist (ie, international normalized ratio [INR] goal > 3) or the addition of low-dose aspirin should be considered.9,10
Factor Xa inhibitors are generally not recommended at this time due to the lack of evidence to support their use.10 Additionally, a randomized clinical trial comparing rivaroxaban and warfarin in patients with triple antiphospholipid antibody positivity was terminated prematurely due to increased thromboembolic events in the rivaroxaban arm.11
For patients with secondary APS in the setting of SLE, hydroxychloroquine in combination with a vitamin K antagonist has been shown to decrease the risk for recurrent thrombosis compared with treatment with a vitamin K antagonist alone.12
Our patient was started on a heparin drip and transitioned to an oral vitamin K antagonist with an INR goal of 2 to 3. Lifelong anticoagulation was planned. The pain and discoloration in her hands improved on anticoagulation and had nearly resolved by the time of discharge. Given her history of arterial thrombosis, the addition of aspirin was also considered, but this decision was ultimately deferred to her outpatient rheumatologist and hematologist.