Dr Erkan made the point that “major bleeding is a poor prognostic factor in CAPS patients, and anticoagulation should be started as soon as possible, sometimes despite minor bleeding.” However, the timing of the anticoagulation is a real challenge. Dr. Erkan and others studied APS patients who developed bleeding, and came to the conclusion that “whatever decision you make with respect to the timing of the anticoagulation, things can go wrong.”1 Starting too early can lead to more bleeding; too late, more thrombosis.
“There is no right answer,” he said. “Somebody needs to make a decision.” One compromise might be to start a very low dose and then increase it if the patient can tolerate it.
“One way or another, rheumatologists will see patients in intensive care who have multiple blood clots,” Dr. Erkan said. “Catastrophic APS should always be considered in these patients. Early diagnosis and aggressive treatment are absolutely essential to obtain a positive outcome.” He also stressed the importance of not overdiagnosing CAPS, especially when patient have other thrombosis risk factors and nonsignificant aPL profiles.
Thomas Collins is a freelance medical journalist based in Florida.
Reference
- Silverberg M, Erkan D, Lockshin MD. Hemorrhage in the antiphospholipid syndrome: The challenge of anticoagulation. Arthritis Rheum. 2003;46:S52.
