Patients with antiphospholipid antibodies (aPL) are at increased risk for arterial or venous thrombosis. There is, however, significant heterogeneity among patients according to clinical and laboratory features. Therefore, two therapeutic modalities can be discussed for primary prevention of thrombosis in patients: (1) primary prophylaxis in all aPL patients or (2) only in selected high-risk patients. Because aPL are often diagnosed in patients with systemic lupus erythematosus before occurrence of a first thrombosis, primary prophylaxis should be specifically discussed in this setting.
Risk for thrombosis in lupus patients may be increased by additional clinical risk factors, in particular hypertension. Laboratory profile is also important: lupus anticoagulant, double (any combination of lupus anticoagulant, anticardiolipin antibodies or anti-b2 glycoprotein I antibodies) or triple (all three subtypes) aPL positivity, as well as the presence of persistently high aPL titres indicate high risk patients. Specific risk scores may be helpful such as the global antiphospholipid syndrome score (GAPSS).
Observational data indicate that low dose aspirin reduces the risk of first thrombosis in aPL patients, particularly in those with lupus (by 50%) with a low bleeding risk. To improve the risk:benefit ratio, prescribe aspirin in patients with high-risk profiles and low bleeding risk.
Treatment failure may be due to aspirin resistance (insufficient dosage, poor absorption or drug interaction) or poor treatment adherence (long term prophylactic treatment in young patients) of which the attending physician must be aware.
In summary, prophylactic low dose aspirin in aPL positive lupus patients should be considered taking into account thrombotic and bleeding risks. Because of its long-term objectives, this treatment should be carefully explained and discussed with the patient before taking a shared decision.
Explain when primary prophylaxis should be used for APL
Describe the risk factors for thrombosis in patients with lupus
Discuss optimal treatment options for thrombosis risk reduction in patients with aPL
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