From the Guidelines
For patients with single positivity antiphospholipid syndrome (APS), the use of direct oral anticoagulants (DOACs) in combination with aspirin is not the preferred initial treatment approach, and instead, low-dose aspirin alone or vitamin K antagonists like warfarin are typically considered based on the patient's thrombotic history and risk factors. The management of APS, particularly in cases of single positivity, hinges on balancing the risk of thrombosis against the risk of anticoagulant-related bleeding. According to the evidence from 1, the standard treatment for thrombotic APS remains vitamin K antagonists, with DOACs being considered in specific scenarios where traditional anticoagulants are not suitable.
For primary prophylaxis in patients with single positive antiphospholipid antibody without prior thrombosis, low-dose aspirin (81-100 mg daily) may be an appropriate consideration, especially in the presence of additional cardiovascular risk factors. This approach is supported by the understanding that aspirin can provide some level of protection against thrombotic events without the increased risk of bleeding associated with more potent anticoagulants.
In cases where the patient has experienced a thrombotic event, warfarin with a target INR of 2-3 is generally preferred over DOACs due to its established efficacy in preventing recurrent thrombosis in APS patients. The evidence suggesting DOACs may be less effective than warfarin in this context, particularly in those with triple-positive antibody status, guides this recommendation 1. While DOACs might be considered for patients who cannot tolerate warfarin or have issues with stable INR management, this should be done with caution and after thorough discussion with the patient about the potential risks and benefits.
Key considerations in the management of single positivity APS include:
- The patient's history of thrombotic events
- The presence of additional cardiovascular risk factors
- The ability to safely manage anticoagulation therapy
- The patient's preferences and values regarding treatment options
Ultimately, the decision to use DOACs, aspirin, or traditional anticoagulants in the management of single positivity APS should be individualized, taking into account the latest evidence and guidelines, as well as the specific clinical context and patient factors 1.
From the Research
Treatment of Single Positivity Antiphospholipid Syndrome
- The use of direct oral anticoagulants (DOACs) and aspirin in patients with single positivity antiphospholipid syndrome is a topic of ongoing research and debate 2, 3, 4, 5, 6.
- A study published in the European journal of haematology in 2022 found that DOACs may be a safe and effective option for patients with single-positive antiphospholipid syndrome, with no significant difference in recurrent thrombotic events or major bleeding compared to warfarin 2.
- However, another study published in Seminars in thrombosis and hemostasis in 2023 suggested that the role of DOACs in thrombotic antiphospholipid syndrome is still unclear and that single or double antiphospholipid positivity should be analyzed on a case-by-case basis 3.
- A position statement from German societies published in VASA in 2019 recommended that patients with single or double positive antiphospholipid antibodies but without positive lupus anticoagulant may have a comparably low thrombotic risk and may be treated with a DOAC, but emphasized the need for careful diagnostic testing and individualized treatment decisions 5.
- A case series published in the Journal of investigative medicine high impact case reports in 2022 evaluated the use of apixaban in patients with antiphospholipid syndrome and found that while some patients tolerated apixaban, others experienced recurrent venous thromboembolism and bleeding complications, highlighting the need for further research on the safety and effectiveness of DOACs in this population 6.
Use of Aspirin in Single Positivity Antiphospholipid Syndrome
- There is limited evidence on the use of aspirin in combination with DOACs for the treatment of single positivity antiphospholipid syndrome.
- The studies reviewed did not provide clear guidance on the use of aspirin in this context, and further research is needed to determine the safety and effectiveness of this treatment approach 2, 3, 4, 5, 6.