From the Guidelines
Eliquis (apixaban) is not recommended for use in antiphospholipid syndrome (APS) due to its association with excess thrombotic events compared to warfarin, particularly in high-risk patients with triple-positive antiphospholipid antibodies or a history of thrombosis. The 2021 guideline from the American Heart Association/American Stroke Association 1 suggests that in patients with ischemic stroke or TIA who meet the criteria for APS, anticoagulation with warfarin is recommended to reduce the risk of recurrent stroke or TIA. Furthermore, the guideline advises against the use of rivaroxaban, another direct oral anticoagulant (DOAC), in patients with APS and a history of thrombosis, citing an increased risk of thrombotic events 1. This caution is likely applicable to other DOACs like Eliquis, given their similar mechanisms of action. Key considerations for APS management include:
- The need for anticoagulation to prevent recurrent thrombotic events
- The choice of anticoagulant, with warfarin being preferred over DOACs like Eliquis for high-risk APS patients
- The importance of careful patient selection and monitoring when considering alternative anticoagulants, such as in cases where warfarin is not tolerated. In such scenarios, the decision to use Eliquis or any other DOAC should be made under specialist guidance, weighing the potential benefits against the increased risk of thrombosis 1.
From the FDA Drug Label
- 6 Increased Risk of Thrombosis in Patients with Triple Positive Antiphospholipid Syndrome Direct-acting oral anticoagulants (DOACs), including Apixaban Tablets, are not recommended for use in patients with triple-positive antiphospholipid syndrome (APS) For patients with APS (especially those who are triple positive [positive for lupus anticoagulant, anticardioplipin, and anti-beta 2-glycoprotein I antibodies]), treatment with DOACs has been associated with increased rates of recurrent thrombotic events compared with vitamin K antagonist therapy.
Eliquis (apixaban) is not recommended for use in patients with triple-positive antiphospholipid syndrome (APS) due to increased risk of recurrent thrombotic events compared to vitamin K antagonist therapy 2.
From the Research
Eliquis in Antiphospholipid Syndrome
- The use of Eliquis (apixaban) in patients with antiphospholipid syndrome (APS) has been explored in several studies, with mixed results 3, 4, 5.
- A case series study found that apixaban may have some safety and effectiveness concerns in APS patients, with recurrent venous thromboembolism (VTE) and bleeding complications reported 3.
- A randomized trial comparing apixaban with warfarin in patients with thrombotic antiphospholipid syndrome (TAPS) found that apixaban may not be routinely substituted for warfarin to prevent recurrent thrombosis, especially strokes 4.
- Another study discussed the potential use of new oral anticoagulants (NOACs), including apixaban, in APS patients, highlighting the need for prospective clinical studies to assess their safety and efficacy in this population 6.
- The ASTRO-APS study, a prospective randomized open-label blinded event pilot study, aims to compare the safety and efficacy of apixaban with warfarin in patients with APS for the secondary prevention of thrombosis 5.
Comparison with Warfarin
- Warfarin remains the standard treatment for APS patients, but its use can be challenging due to the need for monitoring and dose adjustments 7, 6.
- The RAPS protocol, a phase II/III clinical trial, aims to demonstrate that rivaroxaban is not inferior to warfarin in patients with APS and previous VTE 7.
- The study by 4 found that apixaban may not be as effective as warfarin in preventing recurrent thrombosis in TAPS patients.