Dosing considerations in the use of the direct oral anticoagulants in the antiphospholipid syndrome
Dosing considerations in the use of the direct oral anticoagulants in the antiphospholipid syndrome
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DOI：
10.1111/jcpt.12582
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发表时间：
2018-02-01
影响因子：
2
通讯作者：
Hassell, K.
中科院分区：
文献类型：
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作者：
Schofield, J. R.;Hassell, K.
已知信息和目标至少有四项前瞻性试验已启动，研究直接口服抗凝剂治疗抗磷脂综合征的效果。初步报告支持它们在有静脉血栓形成史且目标 INR 为 2-3 的患者中使用，但也有报道称这些药物在抗磷脂综合征中失败。目的是提供一份病例报告，说明在抗磷脂综合征患者中考虑使用这些药物时可能存在重要的剂量问题。病例摘要一名患有抗磷脂综合征的 50 岁女性，临床表现为复发性坏疽性脓皮病样腿部溃疡，接受阿哌沙班治疗，溃疡愈合得到改善。出于保险目的，她因溃疡恶化而改用利伐沙班，当恢复阿哌沙班治疗时，溃疡再次改善。新内容和结论尽管半衰期、药代动力学和药效学相似，但制造商推荐的阿哌沙班维持剂量为每天两次，利伐沙班每天一次。我们相信推荐剂量的这种差异解释了本病例报告中指出的不同临床反应，并且这些药物的每日两次给药和每日较大剂量可能对强效高凝性疾病（例如抗磷脂综合征）更有效。
What is known and objectivesAt least four prospective trials have been initiated investigating the direct oral anticoagulants in the antiphospholipid syndrome. Preliminary reports have supported their use in patients with a history of venous thrombosis and a target INR of 2-3, but there have also been reports of failure of these agents in the antiphospholipid syndrome. The objective is to present a case report that illustrates there may be important dosing issues when considering the use of these agents in patients with the antiphospholipid syndrome.Case summaryA 50-year-old woman with the antiphospholipid syndrome, manifesting clinically with recurrent pyoderma gangrenosum-like leg ulcers, was treated with apixaban, resulting in improved ulcer healing. For insurance purposes, she was switched to rivaroxaban with worsening of the ulcers which again improved when apixaban was resumed.What is new and conclusionDespite a similar half-life, pharmacokinetics and pharmacodynamics, the manufacturer-recommended maintenance dosing of apixaban is twice daily and rivaroxaban once daily. We believe this difference in recommended dose accounts for the differential clinical response noted in the present case report and that twice daily dosing and a larger daily dose of these agents may be more efficacious in potent hypercoagulable disorders, such as the antiphospholipid syndrome.