Low-molecular-weight heparin in patients with antiphospholipid syndrome
| Clinical indications for consideration of LMWH in patients with APS: • Anticoagulant-refractory thrombotic APS (anticoagulant is warfarin/VKA) • CAPS • Pregnancy • Warfarin/VKA intolerance • Bleeding concerns with warfarin/VKA Dosing: Weight-based dosing, without anti-Xa monitoring, is generally appropriate Careful review of LMWH dose during periods of thrombocytopenia | Monitoring: Monitor platelets for HIT: • during LMWH use after major surgery or major trauma (intermediate risk, 0.1%-1.0%) • not required in medical or obstetric patients or after minor surgery or trauma (low risk, <0.1%)45 ASH VTE guidance suggests (with low/very low certainty) against anti-Xa monitoring in: • pregnancy • renal impairment (creatinine clearance <30mL/min), favoring fixed dose reduction per manufacturer's recommendations • obesity, favoring dosing by actual body weight (uncapped) Limitations of chromogenic anti-Xa assays for monitoring LMWH include: • clinical utility uncertain • not universally available • suboptimal reproducibility and interlaboratory variation |
| Clinical indications for consideration of LMWH in patients with APS: • Anticoagulant-refractory thrombotic APS (anticoagulant is warfarin/VKA) • CAPS • Pregnancy • Warfarin/VKA intolerance • Bleeding concerns with warfarin/VKA Dosing: Weight-based dosing, without anti-Xa monitoring, is generally appropriate Careful review of LMWH dose during periods of thrombocytopenia | Monitoring: Monitor platelets for HIT: • during LMWH use after major surgery or major trauma (intermediate risk, 0.1%-1.0%) • not required in medical or obstetric patients or after minor surgery or trauma (low risk, <0.1%)45 ASH VTE guidance suggests (with low/very low certainty) against anti-Xa monitoring in: • pregnancy • renal impairment (creatinine clearance <30mL/min), favoring fixed dose reduction per manufacturer's recommendations • obesity, favoring dosing by actual body weight (uncapped) Limitations of chromogenic anti-Xa assays for monitoring LMWH include: • clinical utility uncertain • not universally available • suboptimal reproducibility and interlaboratory variation |