Challenges of anticoagulation in patients with systemic lupus erythematosus

Area of Science:

• Rheumatology
• Cardiology
• Hematology

Background:

• Systemic lupus erythematosus (SLE) patients exhibit a high incidence of cardiovascular disease and thrombosis.
• Disease pathophysiology, antiphospholipid syndrome (APS) overlap, comorbidities, and treatment complications contribute to thrombotic risks in SLE.

Purpose of the Study:

• To outline the epidemiology and pathophysiology of cardiovascular disease and thrombosis in SLE, with or without APS.
• To discuss cardiovascular comorbidities and thrombotic disorders associated with SLE and/or APS.
• To highlight current anticoagulation management guidelines and disease-specific considerations, focusing on direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) in SLE patients.

Main Methods:

• Review of current literature and guidelines on cardiovascular disease and thrombosis in SLE and APS.
• Epidemiological and pathophysiological analysis of thrombotic events in SLE.
• Discussion of anticoagulation strategies, including warfarin and DOACs, with a focus on specific patient populations.

Main Results:

• Cardiovascular risk assessment and antiphospholipid (aPL) profiling are crucial for SLE patients.
• Warfarin is generally preferred for high-risk APS patients.
• DOACs are a viable option for selected SLE/APS patients with VTE and no history of arterial thrombosis.

Conclusions:

• Anticoagulation management in SLE, particularly with APS, requires careful consideration of individual patient factors.
• Initiating anticoagulation in Catastrophic APS (CAPS) presents significant challenges.
• Further research is needed to address knowledge gaps in managing recurrent thrombosis despite anticoagulation and to optimize thrombotic event reduction strategies in APS.