Should patients with Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA), and Sjögren's syndrome be on Oral Anticoagulant (OAC) or Antiplatelet (OAP) therapy?

Anticoagulation and Antiplatelet Therapy in SLE, RA, and Sjögren's Syndrome

Patients with SLE who have high-risk antiphospholipid antibody (aPL) profiles should receive primary prophylaxis with antiplatelet agents, while those with RA and Sjögren's syndrome generally do not require routine anticoagulation unless specific risk factors are present. 1, 2

SLE Patients and Thrombotic Risk

Antiphospholipid Antibodies in SLE

• All SLE patients should be screened for aPL at diagnosis 1
• High-risk aPL profile includes:
  • Persistently positive medium/high titers of aPL
  • Multiple aPL positivity (triple positivity)
  • Presence of lupus anticoagulant

Primary Prevention Recommendations

• For SLE patients with high-risk aPL profile:
  • Low-dose aspirin is recommended, especially with additional risk factors 1, 2
  • Consider individual bleeding risk when making this decision 1

Secondary Prevention (after thrombosis/pregnancy complications)

• For SLE patients with previous thrombotic events:
  • Treatment approach should be the same as for primary antiphospholipid syndrome 1
  • Venous thrombosis: Warfarin with target INR 2.0-3.0 2
  • Arterial or recurrent thrombosis: Higher intensity anticoagulation with target INR 3.0-4.0 2

Cardiovascular Disease Prevention

• SLE patients should undergo regular assessment for:
  • Traditional cardiovascular risk factors
  • Disease-related risk factors (persistent disease activity, increased disease duration, aPL, renal involvement, chronic glucocorticoid use) 1
• Low-dose aspirin may be considered for primary CVD prevention based on individual risk profile 1
• Statins should be considered based on lipid levels and presence of other traditional risk factors, not routinely for all patients 1

Neuropsychiatric SLE and Anticoagulation

• For cerebrovascular disease related to aPL:
  • Antiplatelet and/or anticoagulation therapy is recommended 1
  • Anticoagulation may be superior to antiplatelet therapy for secondary prevention of arterial events 1
• For other NPSLE manifestations associated with aPL (ischemic optic neuropathy, chorea, myelopathy):
  • Consider antiplatelet/anticoagulation therapy if refractory to immunosuppressive therapy 1

Rheumatoid Arthritis and Sjögren's Syndrome

Sjögren's Syndrome

• No specific guidelines recommend routine anticoagulation or antiplatelet therapy for Sjögren's syndrome 3
• Thromboembolic events are not common in primary Sjögren's syndrome compared to SLE 3
• Consider anticoagulation only if:
  • Antiphospholipid antibodies are present
  • Patient develops thrombotic complications

Rheumatoid Arthritis

• No specific guidelines recommend routine anticoagulation or antiplatelet therapy for RA alone
• Consider cardiovascular risk assessment and appropriate preventive measures based on traditional risk factors

Important Considerations

Risk Stratification

• Assess for additional thrombotic risk factors:
  • Advanced age
  • Diabetes mellitus
  • Renal involvement
  • Immunosuppressive therapy
  • Glucocorticoid use 1
  • Hypertension 4
  • Disease activity and duration 4

Monitoring

• Regular assessment of disease activity using validated indices
• Monitoring of anti-dsDNA antibodies and complement levels
• Evaluation of accumulated damage using SLICC/ACR index 2

Cautions

• Balance thrombotic risk against bleeding hazard, especially in elderly patients 1
• Direct oral anticoagulants (DOACs) like rivaroxaban should be used with caution in APS with triple aPL positivity due to increased risk of thromboembolic events 1
• Consider additional anticoagulant treatment during high-risk periods (pregnancy, postoperative) 1

In summary, anticoagulation and antiplatelet therapy decisions should be based on the presence of specific risk factors, particularly antiphospholipid antibodies in SLE patients, while routine prophylaxis is not recommended for RA or Sjögren's syndrome without additional risk factors.