Risk for thrombotic recurrence outweighs therapy cessation in antiphospholipid syndrome
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Although patients with antiphospholipid syndrome may ask to halt their anticoagulation if their symptoms are stable, there remains serious risk for recurrent thrombosis, noted a presenter at the 2020 Congress of Clinical Rheumatology-West.
“One major clinical problem or discussion that I often have with the patients in my office is ‘could we stop the anticoagulant therapy?’” Maarten Limper, MD, PhD, an internist-clinical immunologist at the University Medical Center Utrecht, in the Netherlands, told attendees. “I think the short answer is that we should not do that.”
Limper cited data from a 2017 study in Lupus by Comarmond and colleagues, which followed the occurrence of recurrent thrombotic events among 44 patients with antiphospholipid syndrome (APS) after stopping oral anticoagulant treatment. Patients were switched from vitamin K antagonists for a number of different reasons, Limper noted, including bleeding complications and the prolonged disappearance of antiphospholipid (aPL) antibodies.
“In the end, 25% of these patients — 11 out of 44 — had a recurrence of thrombosis,” Limper said. “It’s a small cohort, only 44 patients, but this is real life, and a 25% recurrence is something to think about.”
In the 2017 study by Yelnik and colleagues, also published in Lupus, 30 patients with thrombotic APS whose anticoagulation therapy was withdrawn following diagnosis were then match-controlled with patients under anticoagulation, based on sex, age, APS clinical phenotype and disease duration.
“In the cases, there was persistent aPL positivity and, in the controls, the aPL disappeared over time,” Limper noted. “What they saw was that those persistently positive patients had a 10-year cumulative thrombotic risk of 54% — over half of the patients had recurrent thrombosis after cessation of oral anticoagulant vs. 13.5% in patients without persistent aPL.”
“You could, of course, say that 13.5% is not so bad, but I think it’s still quite a lot,” Limper said. “What I think you should keep in mind from this study is that in those persistently positive patients, we really should not think about stopping anticoagulants. In the control group, maybe there is room for discussion, but I think it’s not wise to conclude that the risk is low in this group.”
Given these datasets, Limper noted that there is not enough compelling evidence available to recommend withdrawing anticoagulation for patients with APS, but that each case should be assessed individually.
“Should we stop oral therapy in our patients: the short answer, to me, would be no,” Limper said. “Of course, there are situations, in particular when patients have a bleeding tendency, where we should do a risk-benefit analysis, as we should with all drugs that we use. However, we cannot identify patients with a low risk yet. Maybe we will manage to do that later on with different antibody profiles and biomarkers but for now, that is not possible.”
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Limper M. New findings in Long-Standing Antiphospholipid Syndrome. Presented at: Congress of Clinical Rheumatology-West annual symposium; October 8-11, 2020 (virtual meeting).
Comarmond C, et al. Lupus. 2017 doi:10.1177/0961203317699285.
Yelnik CM, et al. Lupus. 2017 doi:10.1177/0961203317721751.
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