What is the recommended long-term anticoagulation strategy for patients diagnosed with APS to prevent thrombotic events?

For patients diagnosed with antiphospholipid syndrome (APS) to prevent thrombotic events, the recommended long-term anticoagulation strategy is to use vitamin K antagonists (VKAs), such as warfarin, targeting an international normalized ratio (INR) of 2.0 to 3.0. This is particularly emphasized for those with established triple positive APS and a history of venous thromboembolism (VTE), where initial treatment with low molecular weight heparin (LMWH) concurrently with a VKA for at least 5 days, or until the INR is therapeutic on two consecutive readings, is advised before continuing VKA alone ².

Direct oral anticoagulants (DOACs) are generally not recommended for patients with triple positive APS due to concerns about efficacy and safety, as highlighted in UK guidelines ². Instead, long-term anticoagulation with warfarin remains the standard of care to reduce the risk of recurrent thrombosis.

In cases where anticoagulation treatment fails, guidelines recommend checking adherence, addressing other hypercoagulable states, and considering increasing the anticoagulant dose or switching to an anticoagulant with a different mechanism of action ².

Supporting literature also underscores the complexity of APS management, noting that while VKAs are the mainstay, treatment must be individualized based on thrombotic risk, antibody profile, and bleeding risk (Espinosa and Cervera, 2015). The literature cautions about the limited role of DOACs in high-risk APS patients and supports the use of warfarin for long-term secondary prevention of thrombosis.

Patients should be provided with comprehensive education about anticoagulation, including monitoring requirements, potential interactions, and the importance of adherence, as well as carrying an anticoagulant alert card at all times ¹,³.