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Venous thromboembolism in the antiphospholipid syndrome: management guidelines for secondary prophylaxis

Department of Internal Medicine, University of Milan, IRCCS Istituto Auxologico Italiano, Milan, Italy, pierluigi.meroni{at}unimi.it

M Moia

A Bianchi Bonomi Haemophilia and Thrombosis Center, IRCCS Ospedale Maggiore, Milan, Italy

R HWM Derksen

Rheumatology and Clinical Immunology Department, University of Utrecht, Utrecht, The Netherlands

A Tincani

Servizio di Allergologia, Immunologia Clinica e Reumatologia, Spedali Civili, Brescia, Italy

J A McIntyre

HLA-Vascular Biology Laboratory, St Francis Hospital and Health Centers, Indiana, USA

J MMC Arnout

Center for Molecular Vascular Biology, Katholieke University of Leuven, Belgium

T Koike

Department of Medicine II, Hokkaido University School of Medicine, Sapporo, Japan

J-C Piette

Department of Internal Medicine, Hospital de la Pitié, Paris, France

M A Khamashta

Lupus Research Unit, Rayne Institute, King’s College, St Thomas’ Hospital, London, UK

Y Shoenfeld

Research Center for Autoimmune Diseases, Internal Medicine ‘B’, Sheba Medical Center, Tel-Hashomer, Israel

Venous thromboembolism(VTE) in patients suffering from the antiphospholipidsyndrome (APS) has been reported in almost any location of the vessel tree and the risk of recurrences has been found in several studies to be more closely associated with the presence of lupus anticoagulant than with the positivity for anti-cardiolipin antibodies. The thrombophilic state of APS raises the problem of the secondary prophylaxis to avoid VTE recurrences. For APS patients with VTE, published data appear to support a longer warfarin treatment if compared with the standard management of anti-phospholipid (aPL)-negative patients with VTE. The question of how long oral anticoagulant treatment should be continued for APS patients, however, remains unanswered. Concerning the intensity of anticoagulation, several authors recommend a target international normalized ratio (INR) between 3.0 and 4.0 to efficiently protect from VTE recurrences.A recentdecisionanalysisstudy does support such a suggestion. On the contrary, in a few prospective studies regimens with lower target INRs appear to be effective, and some authors therefore recommend a target INR of between 2.0 and 3.0. Specific large and prospective trials are needed to address this question. Until such information becomes available, individualized treatment according to the patient’s individual risk factors for both bleeding and thrombosis is the general practice.

Key Words: anti-phospholipid antibodies • oral anticoagulation • venous thrombosis

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