Antiphospholipid Syndrome: State of the Art of Clinical Management

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder clinically characterized by recurrent arterial and venous thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies. Currently, treatment is mainly focused on anticoagulation, but therapies targeting mechanisms involved in APS autoimmune pathogenesis could play an important role in specific settings. An evidence-based therapeutic approach is limited by the broad clinical spectrum of the syndrome and the nature of a rare disease that makes it difficult to carry out well-designed prospective studies. Vitamin K antagonists (AVK), notably warfarin, are the standard treatment for preventing recurrent venous thrombosis and perhaps also arterial thrombosis. Direct oral anticoagulants (DOACs) are not recommended at least in patients with triple positivity APS. Treatment options for the prevention of pregnancy complications in obstetric APS, as combined use of aspirin and heparin, low-dose prednisolone, hydroxychloroquine, intravenous immunoglobulin (IVIG), may improve pregnancy outcome. The catastrophic antiphospholipid syndrome (CAPS) is the most severe form of APS with acute multiple organ involvement and small vessel thrombosis. Glucocorticoids, heparin, plasma exchange or IVIG, rituximab, or eculizumab must be added to concurrent treatment of precipitating factors (e.g. infections) as rescue therapies. Finally, it has been observed that SARS COV2 infection may produce vascular complications mimicking the clinical and pathophysiological features of APS and particularly of CAPS. From this point of view, attention has been focused on the protective role of anticoagulant therapy in preventing thrombotic complication when these clinical conditions coexist.

Automated summary

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by recurrent thrombosis and/or pregnancy morbidity. Anticoagulation is the main treatment, but therapies targeting APS autoimmune pathogenesis have potential. Vitamin K antagonists (AVK) like warfarin are standard for venous thrombosis prevention. Direct oral anticoagulants (DOACs) aren't recommended for triple positive APS. Pregnancy complications may be improved with aspirin and heparin, prednisolone, hydroxychloroquine, IVIG. Catastrophic APS (CAPS) requires glucocorticoids, heparin, plasma exchange or IVIG, rituximab, or eculizumab. SARS COV2 infection may mimic APS, and anticoagulant therapy may be protective in this situation.