Oral Direct Anticoagulants in Thrombosis Management in Anti-Phospholipid Syndrome: Unanswered Questions

Anti-phospholipid syndrome comprises a broad spectrum of manifestations with thrombotic events as a serious issue. The current mainstay of treatment for thrombotic anti-phospholipid syndrome is heparin followed by long-term anticoagulation with vitamin K antagonists. Vitamin K antagonists’ management in this group of patients is frequently cumbersome, requires close monitoring and may affect patient’s quality of life. There is also a high recurrence rate in high risk patients. The introduction of the oral direct inhibitors of coagulation for the management for thromboembolism is currently established for several indications. These agents are fixed dose with predictable anticoagulant effect and do not interact with dietary constituents and have few drug interactions. They have a rapid onset of action and don’t routinely require monitoring. The shortcomings of vitamin K antagonists and the advantages of the oral direct inhibitors encouraged their trial in antiphospholipid syndrome. Case series of their use paved the road for designing clinical trials aiming to study their potential role in this important group of patients. In this article, we reviewed the literature regarding the current state of oral direct anticoagulants in thrombosis management in general, cited the case series results and presented the ongoing clinical trials that are currently underway. We also raise some practical points relevant to their application in specific situations. It is premature to pass comments on their applicability, but the seriousness of the issue