Management of patients with antiphospholipid antibodies: what to do in laboratory scenarios that do not fit the guidelines

ABSTRACT

Introduction: Some patients with positive antiphospholipid antibodies (aPL) have not been included in randomized clinical trials or observational registries and, therefore, information on their risk of obstetric or thrombotic recurrence and optimal treatment is scarce.

Areas covered: In the present review, the existing evidence regarding the management of two laboratory scenarios not covered by the guidelines is presented: (1) patients with antiphospholipid syndrome (APS) clinical manifestations and aPL positivity not fulfilling APS laboratory criteria, and (2) the possibility of discontinuing anticoagulation in APS patients whose aPL become persistently negative.

Expert opinion: Growing evidence suggests a role for low titers and ‘non-criteria’ aPL, especially in obstetric APS. Treatment is not formally recommended but might be considered according to the individual’s risk profile. Regarding the question of whether or not to discontinue anticoagulants after the ‘spontaneous’ disappearance of aPL, there is no definite answer. Retrospective studies seem to suggest that withdrawal of anticoagulation could be safe in certain patients with APS, especially in those with a first provoked venous thrombosis and whose aPL became persistently negative during follow-up. Still, before the withdrawal can be recommended in routine clinical practice, multicenter and prospective studies are required to validate this hypothesis.

KEYWORDS:

• Antiphospholipid syndrome
• antiphospholipid antibodies
• low titer
• non-criteria laboratory
• negativization of aPL

Article highlights

• A rising number of publications hint the importance of low titers and ‘non-criteria’ aPL, with most data available addressing obstetric APS.

• Treatment of patients with these laboratory scenarios, although not formally recommended, might be considered after assessing the individual´s risk profile.

• Around 10% of patients who at first fulfill the laboratory classification criteria of APS may afterwards display ‘persistently’ negative aPL or, more importantly from a clinical point of view, a non-clinically meaningful aPL profile.

• The population of APS with this laboratory scenario could have a low-risk thrombotic recurrence and discontinuation of anticoagulant treatment could be an option.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosure

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The paper was not funded.