Would you use new oral anticoagulants (NOACs) for thromboprophylaxis in patients with an underlying hypercoagulable state? A literature review through a case report. (P6.231)

Objective: To present a case of a patient with antiphospholipid syndrome (APLs) on a NOAC for secondary thromboprophylaxis who developed a subsequent stroke, and to discuss the current evidence regarding the use of NOACs in patients with hypercoagulable state. Background: APLs is an autoimmune condition leading to a hypercoagulable state and predisposing to venous and arterial thrombosis. Warfarin is the recommended anticoagulation in APLs patients for thromboprophylaxis. However, warfarin requires frequent INR monitoring, has a prolonged onset of action, and numerous drug interactions. Currently, there is mixed evidence for and against the use of NOACs for thromboprophylaxis in APLs and it remains a controversial topic. Design/Methods: A case report and review of literature. Results: A 48 year-old woman with history of hypertension, hyperlipidemia, beta 2 glycoprotein-positive APLs, and pulmonary embolism (PE) on Apixaban who presented with left homonymous hemianopia. Brain magnetic resonance images showed an acute right occipital lobe ischemic stroke. Transthoracic echocardiogram revealed noninfectious bacterial endocarditis without evidence of cardiac thrombus or shunt. Angiography of head and neck, and studies for systemic lupus erythematous were unremarkable. The suspected etiology of the stroke was NBTE associated with APLs, and given that the patient had a history of PE and experienced an ischemic stroke while on Apixaban, anticoagulation therapy was switched to warfarin with an INR goal of 2 to 3. Conclusions: There is a lack of evidence to support the use of NOACs for anticoagulation in patients with APLs. A recent Cochrane review did not find sufficient evidence to determine the benefit or harm of NOACs versus warfarin use in preventing thrombosis in these patients. There is lack of data suggesting use of NOACs in APLs, hence, the standard of care remains to be warfarin. Randomized controlled trials are warranted in order to prove efficacy for NOAC use. Disclosure: Dr. Kakadia has nothing to disclose. Dr. Daci has nothing to disclose. Dr. Suero-Abreu, MD, PhD has nothing to disclose. Dr. Then has nothing to disclose.