What is the current evidence regarding the use of DOACs in patients with antiphospholipid syndrome?
Observational data suggest a high risk of recurrent thrombosis among patients with antiphospholipid syndrome who receive DOACs. A noninferiority RCT of patients with established antiphospholipid syndrome and triple-positive antiphospholipid antibodies showed a higher risk of thrombotic events with rivaroxaban compared to VKA. However, there was no statistical interaction suggestive of a differential effect among those with antiphospholipid syndrome and 1 or 2 antiphospholipid antibodies. Until other ongoing trials such as ASTRO-APS clarify whether the increased risk of thrombosis with DOACs is a class effect versus an individual drug effect, DOACs in general and, specifically, rivaroxaban are not recommended for antiphospholipid syndrome.