This handout is for antiphospholipid syndrome (aps) dvt — warfarin preferred, doac avoided. Your care team identified this based on: unilateral leg swelling/pain with prior aps diagnosis or strong aps suspicion (recurrent vte, arterial + venous events, pregnancy morbidity, autoimmune disease — particularly sle).
Other reasons your team may use this plan: unprovoked vte in patient with ≥3 consecutive miscarriages <10 wk or ≥1 fetal death ≥10 wk or severe preeclampsia/placental insufficiency — sapporo/sydney pregnancy-morbidity criteria; patient with both prior arterial event (stroke, mi, tia) and venous event — aps until proven otherwise; unexplained aptt prolongation that does not correct with mixing study — lupus anticoagulant suspected.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| warfarin | 5 mg PO daily; target INR 2-3 (first venous APS event), 2.5-3.5 (arterial APS or recurrent venous APS), 3-4 (selected triple-positive cases per expert opinion) | PO | daily lifelong | TRAPS (Pengo Blood 2018 PMID 30196097) — warfarin SUPERIOR to rivaroxaban in triple-positive APS; EULAR 2019 — warfarin first-line; lifelong AC per APS clinical criterion |
| enoxaparin | 1 mg/kg SC BID (reduce to 1 mg/kg SC daily if CrCl <30); overlap with warfarin until INR therapeutic for ≥2 consecutive days | SC | BID | ASH 2020 (PMID 33007077); ASH 2018 pregnancy (PMID 30482767) — LMWH first-line in pregnancy; standard initial AC overlap with warfarin (≥5 d + INR therapeutic ≥2 d) |
| aspirin | 81 mg PO daily | PO | daily | EULAR 2019 — low-dose ASA add-on for arterial APS; antepartum low-dose ASA + LMWH for APS pregnancy improves fetal outcomes; potential benefit in recurrent thrombosis on therapeutic warfarin |
| hydroxychloroquine | 200-400 mg PO daily (max 5 mg/kg/day actual body weight per AAO retinopathy guidance) | PO | daily | EULAR 2019 — hydroxychloroquine adjunct in SLE-associated APS reduces thrombosis recurrence; observational data support adjunct in recurrent APS thrombosis on warfarin |
| heparin | 80 U/kg IV bolus + 18 U/kg/h targeting aPTT 1.5-2.5× (LA may falsely prolong aPTT — use anti-Xa assay if available) | IV | continuous | Reversibility for peri-procedural management; anti-Xa monitoring preferred when LA confounds aPTT (ACCP 2021) |
| AVOID rivaroxaban | AVOID | N/A | N/A | TRAPS (Pengo Blood 2018 PMID 30196097) — trial terminated early for arterial harm in triple-positive APS; ISTH 2020 + EULAR 2019 advise against rivaroxaban in APS |
| AVOID apixaban in APS | AVOID | N/A | N/A | ASTRO-APS apixaban arm (Woller Blood Adv 2022) — terminated for harm in arterial APS; class effect concern; EULAR 2019 |
| methylprednisolone | CAPS: methylprednisolone 1 g IV daily × 3 d → taper | IV | daily | CAPS Registry — corticosteroids one of the four pillars (anticoagulation + corticosteroids + plasma exchange + IVIG ± rituximab/eculizumab) in CAPS; mortality benefit in observational data |
| fentanyl | 25-100 µg IV q5-10 min titrate | IV | PRN | Pain control; CAPS multi-organ ischemia is severely painful; reduces sympathetic drive |
Plan: Antiphospholipid syndrome anticoagulation — WARFARIN preferred (INR target by phenotype), LMWH in pregnancy, DOAC INFERIOR and avoided (TRAPS, ASTRO-APS, EULAR 2019)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Hematology + rheumatology co-management; reproductive planning for women (LMWH + low-dose ASA antepartum + 6-wk postpartum; hydroxychloroquine adjunct); estrogen avoidance lifelong; cardiovascular risk modification; APS patient card for emergency providers; no DOAC prescription warning in EHR
Guideline: EULAR 2019 APS management + ASH 2020 VTE Treatment + ASH 2018 thrombophilia testing + ASH 2018 VTE in Pregnancy + ACCP/CHEST 2021 + 2023 ACR/EULAR APS classification criteria