Recurrent Thrombosis With Direct Oral Anticoagulants in Antiphospholipid Syndrome: A Systematic Literature Review and Meta-analysis

Purpose: The treatment of thrombosis in patients with antiphospholipid syndrome (APS) usually requires long-term anticoagulation with vitamin K antagonists. The effectiveness of direct oral anticoagulants (DOACs) in APS has not been fully addressed. The purpose of this research was to analyze the efficacy (thrombotic event-free time) and tolerability (bleeding events) of DOACs in patients with APS. Methods: We performed a descriptive analysis of a systematic review of data from patients with APS treated with DOACs reported in the literature, via EMBASE, PubMed, and the European League Against Rheumatism and American College of Rheumatology congresses. After systematic review, a meta-analysis of data from clinical trials was performed. Findings: A total of 728 patients, accounting for 731 courses of treatment with DOACs, were identified. The majority (48.3%) presented with triple anti-phospholipid antibody positivity. The prevalence of thrombosis during DOAC treatment was 13.9%. Analysis of risk factors for recurrent thrombosis suggested that a higher mean (SD) number of prior thrombotic events (1.80 [0.87] vs 1.67 [1.45]; P = 0.012), history of combined arterial and venous thrombosis (27.3% vs 9.2% [P < 0.0001]; odds ratio [OR] = 3.72 [95% CI, 1.91-7.25]), previous treatment with LMWH (9.8% vs 1.1% [P = 0.04]; OR = 9.95 [95% CI, 1.08-91.97]), use of immunosuppressant treatment (41.7% vs 12.7% [P = 0.03]; OR = 4.9 [95% CI, 1.21-19.76]), and no reason to switch anticoagulant treatment other than patient's decision (32% vs 2.8% [P = 0.001]; OR = 16.24 [95% CI, 3.16-83.52]) were associated with a high risk for re-thrombosis. Meta-Analysis did not show statistically relevant difference in risk of thrombosis or bleeding comparing warfarin with DOACs. (C) 2019 Published by Elsevier Inc.