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APS VTE Switch to Warfarin — RACP Adult Medicine MCQ

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HardHaematologyAPS VTE Switch to WarfarinRACP Adult Medicine

A 55-year-old man with antiphospholipid syndrome (triple positive: LA + aCL + anti-β2GPI) has a second unprovoked PE despite 6 months of rivaroxaban (therapeutic dosing confirmed). He is adherent. What is the most appropriate change in anticoagulation?

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Correct answer: A — Lifelong warfarin

Recurrent VTE on a DOAC in triple-positive APS — switch to warfarin (target INR 2.0-3.0 or 2.5-3.5 if arterial events). The TRAPS trial demonstrated inferior outcomes with rivaroxaban compared to warfarin in triple-positive APS (increased thrombotic events). DOACs are CONTRAINDICATED in triple-positive APS. Lifelong warfarin anticoagulation is required. LMWH is an acceptable alternative if warfarin is not tolerated.

Reference: EULAR – 2019 – APS; TRAPS Trial; ISTH 2024