What is the treatment for Acute Pharyngitis (AP) or Antiphospholipid Syndrome (APS)?

Treatment of Antiphospholipid Syndrome (APS)

For patients with confirmed thrombotic APS, initiate adjusted-dose warfarin targeting INR 2.0-3.0 as first-line therapy; for obstetric APS during pregnancy, use combined low-dose aspirin (81-100 mg daily) plus prophylactic-dose low molecular weight heparin (LMWH) throughout pregnancy and 6-12 weeks postpartum. 1, 2

Treatment Algorithm Based on Clinical Presentation

Thrombotic APS (Venous or Arterial Thrombosis)

Primary anticoagulation strategy:

• Start warfarin with target INR 2.5 (range 2.0-3.0) for long-term anticoagulation 1, 2
• For venous thrombosis specifically, maintain INR 2.0-3.0 1, 2
• For arterial thrombosis, consider higher intensity anticoagulation (INR 3.0-4.0) based on individual bleeding versus recurrence risk 1, 2

Critical contraindication:

• Avoid direct oral anticoagulants (DOACs) entirely in triple-positive APS patients due to significantly increased risk of recurrent arterial thrombosis, particularly stroke 1, 2, 3
• If a triple-positive patient is already on a DOAC, immediately transition to warfarin 2

Refractory cases:

• Add antiplatelet therapy (low-dose aspirin) to anticoagulation 2, 3
• Consider adding hydroxychloroquine, especially in patients with underlying systemic lupus erythematosus 4, 2
• For patients failing standard therapy, increase target INR range 2

Obstetric APS

During pregnancy:

• Combined therapy with low-dose aspirin (81-100 mg daily) plus prophylactic-dose LMWH is mandatory throughout pregnancy 4, 2, 3
• Start aspirin in the first trimester, ideally before 16 weeks 4, 2
• Never use warfarin during pregnancy due to teratogenicity in the first trimester 1

For thrombotic APS in pregnancy:

• Escalate to therapeutic-dose LMWH (not prophylactic-dose) plus low-dose aspirin throughout pregnancy and postpartum 4, 2

Postpartum management:

• Continue prophylactic-dose anticoagulation for 6-12 weeks postpartum in obstetric APS 4
• For thrombotic APS, continue therapeutic anticoagulation postpartum 4

Adjunctive therapy:

• Add hydroxychloroquine to standard heparin/aspirin therapy for primary APS, as recent studies suggest decreased complications 4, 2
• Continue hydroxychloroquine throughout pregnancy if already prescribed 3

Asymptomatic Antiphospholipid Antibody-Positive Patients

Primary prevention strategy:

• Low-dose aspirin (75-100 mg daily) for high-risk antibody profiles including: 2, 3
  • Triple-positive antibodies (lupus anticoagulant + anticardiolipin + anti-β2-glycoprotein I)
  • Double-positive antibodies
  • Isolated lupus anticoagulant
  • Persistently positive anticardiolipin at medium-high titers
• No anticoagulation required for asymptomatic patients with positive antibodies alone 1, 2

For non-pregnant adults with history of obstetric APS only:

• Low-dose aspirin (75-100 mg daily) 3

Catastrophic APS (Life-Threatening Emergency)

Aggressive triple therapy approach:

• Intravenous heparin (preferably LMWH due to anti-inflammatory properties) for immediate anticoagulation 5, 6
• High-dose glucocorticosteroids 3, 5, 6
• Plasma exchange 3, 5, 6

Additional interventions:

• Intravenous immunoglobulins 5, 6
• If associated with lupus flare, add cyclophosphamide 5
• Promptly treat precipitating factors: immediate antibiotics if infection suspected, amputation of necrotic tissue, high vigilance in perioperative settings 5

Special Clinical Scenarios

Assisted Reproductive Technology (ART)

For obstetric APS patients undergoing ART:

• Prophylactic LMWH starting at beginning of ovarian stimulation 2
• Withhold LMWH 24-36 hours prior to oocyte retrieval 2
• Resume LMWH following retrieval 2

For thrombotic APS patients undergoing ART:

• Therapeutic-dose anticoagulation (not prophylactic) 2

Contraindication:

• Defer ART if disease is moderately or severely active 2

Contraception in Women with Positive Antiphospholipid Antibodies

Absolute contraindication:

• Estrogen-containing contraceptives are strictly prohibited due to significantly increased thrombosis risk 1, 3

Safe alternatives:

• Intrauterine devices (IUDs) 3
• Progestin-only pills 3

Monitoring and Co-Management

• Regular INR monitoring for patients on warfarin, targeting therapeutic range 1, 2
• Anti-Xa monitoring for patients on LMWH 2
• Triple-positive or double-positive patients with lupus anticoagulant require more intensive monitoring 2
• Co-manage with experienced hematologist, particularly for complex cases 3

Common Pitfalls to Avoid

• Never use DOACs in triple-positive APS—this is associated with increased arterial thrombotic events 1, 2, 3
• Do not discontinue anticoagulation prematurely; thrombotic APS requires lifelong anticoagulation 1, 2
• Do not use warfarin in first trimester of pregnancy; switch to LMWH before conception or immediately upon pregnancy recognition 4, 1
• Avoid invasive procedures during acute thrombotic episodes due to bleeding risk 3
• Do not overlook precipitating factors in catastrophic APS (infection, surgery, trauma) that require simultaneous treatment 5, 6