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Ravi Kumar: Vitamin K Antagonists Remains the Gold Standard in APS
Ravi Kumar/X
Nov 24, 2025, 14:16

Ravi Kumar: Vitamin K Antagonists Remains the Gold Standard in APS

Ravi Kumar, Rheumatologist at Christian Medical College, shared on X:

“Major Trials of DOACs in Antiphospholipid Syndrome (APS)

  1. TRAPS Trial

(Rivaroxaban in High-Risk APS)

Population

  • Triple-positive APS (LA  + aCL  + anti-β2GP1)
  • High-risk group
  • Prior arterial + venous thrombosis

Design

  • Rivaroxaban 20 mg OD vs Warfarin INR 2–3
  • RCT
  • Open-label

Results

  • 12% arterial events (mostly stroke) in rivaroxaban arm
  • 0% events in warfarin arm
  • Trial stopped early due to harm

Conclusion

Rivaroxaban FAILED in triple-positive APS –  Not effective for arterial protection.

2. RAPS Trial

(Rivaroxaban in Venous-Only APS)

Population

  • APS with previous venous thrombosis only
  •  Not restricted for triple-positivity

Design

  • Rivaroxaban vs Warfarin
  • RCT
  • Primary endpoint = lab surrogate (Endogenous Thrombin Potential)
  • Not powered for clinical events

Results

  • Similar lab thrombin profiles between groups
  • No clear increase in events – but too small & too short
  • Could NOT establish non-inferiority for clinical thrombosis

Conclusion

A neutral trial -Does NOT prove DOAC safety in APS.
Not enough evidence to switch stable APS patients to rivaroxaban.

3. ASTRO-APS Trial

(Apixaban in APS)

Population

  • APS with prior thrombosis
  • Mixed-risk (venous + arterial)
  • Included some triple-positive patients

Design

  • Apixaban 5 mg BD vs Warfarin INR 2–3
  • RCT
  • Open-label
  • Stopped early

Results

  •  Higher stroke rate in apixaban arm
  • Multiple arterial events → Safety signal
  • Warfarin group = fewer thrombosis

Conclusion

  • Apixaban failed in APS.
  • Clear evidence against DOAC use in arterial or high-risk APS.

Summary

  • TRAPS → Rivaroxaban failed in triple-positive, arterial APS
  • RAPS → Neutral lab-only trial, no clinical reassurance
  • ASTRO → Apixaban caused more strokes, early termination

Final Message:

Vitamin K antagonists remains the gold standard in APS.
DOACs NOT recommended, especially in:

  • Triple-positive APS
  • Arterial thrombosis
  • Recurrent events.”

Ravi Kumar

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Antiphospholipid Syndrome Apixaban APS ASTRO-APS Trial DOACs Health Hematology Hemostasis Today Medicine RAPS Trial Ravi Kumar Rheumatology Rivaroxaban stroke TRAPS Trial Triple-positive APS Venous Thrombosis Warfarin
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