Not One-Size-Fits-All: Illiasul Ibad Details Antiphospholipid Syndrome Treatment Strategies
Illiasul Ibad, Rheumatologist at Christian Medical College, posted on X:
”1. How to manage Antiphospholipid Syndrome (APS)?
It’s not one-size-fits-all. Management depends on 3 key scenarios:
1. Asymptomatic carrier
2. With thrombosis
3. In pregnancy
Here’s the algorithmic roadmap.
2. How do you manage an asymptomatic aPL-positive patient?
Not everyone needs anticoagulation.
Key:
• Identify CVD risks—>statin
• Look for autoimmune disease—->HCQ
• LDA only for high-risk profiles
APS management begins with risk stratification, not blanket treatment.
3. How to manage APS with thrombosis?
Venous clot → Warfarin (INR 2–3) or LMWH.
Arterial clot → Warfarin + LDA (consider INR 3–4 if recurrent).
DOACs not for APS.
Treatment = lifelong anticoagulation, tailored to site and risk.
4. APS with recurrent thrombosis despite standard warfarin (INR 2–3)?
Next steps:
- Increase intensity (INR 2.5–3.5 or 3–4)
- Switch to long-term LMWH
- Consider fondaparinux
Management needs escalation, not resignation.
5. How to manage pregnancy in women with obstetric APS?
LDA + prophylactic heparin throughout pregnancy:
- ≥3 miscarriages <10 wks
- Fetal loss ≥10 wks
- Delivery <34 wks (eclampsia/placental insufficiency)
Continue LDA + heparin for 6 wks postpartum (safe in breastfeeding)
6. How to manage pregnancy in women with prior thrombotic APS?
- Switch warfarin → heparin before 6th week of gestation
- Add low-dose aspirin (75–100 mg/d)
- Use therapeutic dose heparin (not just prophylactic)
Goal = maternal safety + fetal protection.
7. Pregnancy with recurrent complications despite LDA + heparin?
Next-step options:
- Escalate heparin to therapeutic dose
- Add hydroxychloroquine
- Consider low-dose prednisolone in 1st trimester
IVIG can be tried
For refractory obstetric APS → intensify and individualize care.”
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