Patients who present with LA and recurrent thrombosis are candidates for prolonged or indefinite anticoagulant versus patients who present with LA but without thrombosis. Obstetrical complications such as miscarriages may be prevented by prophylactically placing a patient on aspirin and unfractionated heparin. Patients with LA may be given hydroxychloroquine, a drug used in malaria. It has demonstrated the prevention of thrombosis in this population.
In managing any autoimmune disease, prophylactic therapy is also used during surgery or hospitalization. However, it is essential to make sure you do not put the patient at risk for bleeding. Many of these patients are placed on low-dose aspirin as a primary prevention; however, its efficacy is unproven. Clopidogrel has been shown to be helpful in these patients and useful if patients are allergic to aspirin.
When patients have a thrombotic event, they may be placed on heparin and then transitioned to warfarin for long-term anticoagulation. They are monitored by the international normalized ratio (INR) and may require an INR in the range of 3.0-4.0, which is higher than the recommendation for venous thrombosis (2.0-3.0) and arterial thrombosis (3.0). Significant and repeated thrombotic events require lifelong anticoagulation.
There is limited information on using direct oral anticoagulants in this patient population. The drugs currently do not have an indication for use, so vitamin K antagonists remain the drug of choice. Clinical trials are ongoing to demonstrate the efficacy of these drugs in LA patients.
