Published: 5 September 2019

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Direct-acting oral anticoagulants may not be the best choice for patients with antiphospholipid syndrome

Prescriber Update 40(3): 51
September 2019

Key Messages

  • An increased rate of recurrent thrombotic events has been noted in patients with antiphospholipid syndrome (APS) treated with rivaroxaban compared to those treated with warfarin.
  • APS patients who are triple positive (for lupus anticoagulant, anticardiolipin and anti-beta-2 glycoprotein I antibodies) are at the greatest risk of treatment failure.
  • Other direct-acting oral anticoagulants may also be less effective than warfarin in patients with APS.
  • Consider switching patients with APS requiring anticoagulant therapy to other therapy, such as warfarin.


In a recently-published study investigating anticoagulant treatment in patients with antiphospholipid syndrome (APS), warfarin was significantly more effective at preventing recurrent thromboembolic events than rivaroxaban (Xarelto)1.

APS patients included in the trial were at high risk for thromboembolic events (triple positive for lupus anticoagulant, anticardiolipin and anti-beta-2 glycoprotein I antibodies).

The trial was terminated prematurely due to an excess of thromboembolic events among patients taking rivaroxaban. Thromboembolic events occurred in 7 (12%) of patients taking rivaroxaban compared to no thromboembolic events in patients randomised to warfarin.

Major bleeding occurred in 4 patients (7%) in the rivaroxaban group and 2 patients (3%) in the warfarin group.

There are no completed similar trials for the other direct-acting oral anticoagulants (DOACs) available in New Zealand: apixaban (Eliquis) or dabigatran (Pradaxa). However, since the mechanism of action is similar to rivaroxaban, a precautionary approach is recommended with these DOACs. Please review all patients with APS requiring anticoagulant therapy and consider switching those taking DOACs to other therapy, such as warfarin.

References

  1. Pengo V, Denas G, Zoppellaro G, et al. 2018: Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood 132(13): 1365–71. DOI: 10.1182/blood-2018-04-848333 (accessed 22 July 2019).
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