Key result
Direct oral anticoagulants did not significantly increase the overall risk of recurrent thrombosis compared to Vitamin K antagonists (RR 1.53), but significantly increased the risk in high-risk patients with antiphospholipid syndrome (RR 3.65).
Why the study?
Data comparing direct oral anticoagulants to Vitamin K antagonists for the secondary prevention of thrombosis in antiphospholipid syndrome remain contentious.
Do direct oral anticoagulants prevent thromboembolic events compared to Vitamin K antagonists in patients with antiphospholipid syndrome?
Meta-Analysis (n=1,131)
Do direct oral anticoagulants prevent thromboembolic events compared to Vitamin K antagonists in patients with antiphospholipid syndrome?
Relative Risk: 1.53 (95% CI 0.92–2.55)
p-value: p=0.10
VKAs remain the preferred treatment for high-risk APS patients due to a significantly higher risk of recurrent thrombosis with DOACs, though DOACs may be an appropriate option for low-risk patients.
Background Thromboprophylaxis is the cornerstone strategy for thrombotic antiphospholipid syndrome (APS). Data comparing direct oral anticoagulants (DOACs) to Vitamin K antagonists (VKAs) in the secondary prevention of thrombosis in APS patients remain contentious. Objectives We aim to review and analyze literature on the efficacy and safety of DOACs compared to VKAs in treating patients with APS. A literature search was performed from inception to March 1, 2022. Subgroups were analyzed based on the risk stratification of APS profiles and different DOAC types. Results A total of 9 studies with 1131 patients were included in the meta-analysis. High-risk APS patients (triple positive APS) who used DOACs displayed an increased risk of recurrent thrombosis (RR=3.65, 95% CI:1.49-8.93; I 2 =29%, P=0.005) compared to those taking VKAs. Similar risk of recurrent thrombosis or major bleeding was noted in low-risk APS patients (single or double antibody-positive) upon administering DOACs or VKAs. The utilization of Rivaroxaban was associated with a high risk of recurrent thromboses (RR=2.63; 95% CI, 1.56-4.42; I 2 =0, P=0.0003), particularly recurrent arterial thromboses (RR=4.52; 95% CI, 1.99-10.29; I 2 =0, P=0.18) in overall APS patients. Comparisons of the rate of recurrent thrombosis events and major bleeding events when using dabigatran or apixaban versus VKAs yielded no statistical differences. Conclusions In the absence of contraindications, this meta-analysis suggests that VKAs remain the first-choice treatment for high-risk APS patients, with DOACs a more appropriate option for low-risk APS patients. Different DOACs may exhibit different levels of efficacy and safety for thromboprophylaxis in APS patients and require further exploration.
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Wu et al. (2022) conducted a meta-analysis in Antiphospholipid syndrome (APS) (n=1,131). Direct oral anticoagulants vs. Vitamin K antagonists was evaluated on Recurrent thrombosis (RR 1.53, 95% CI 0.92-2.55, p=0.10). Direct oral anticoagulants did not significantly increase the overall risk of recurrent thrombosis compared to Vitamin K antagonists (RR 1.53), but significantly increased the risk in high-risk patients with antiphospholipid syndrome (RR 3.65).
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