Reader Responses: How would you treat these patients with acute stroke who are positive for lupus anticoagulant or aCL antibodies?

Here’s how readers responded to a You Make the Call question about anticoagulation for patients with antiphospholipid antibodies and a history of stroke.

Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.

I would start anticoagulation but repeat the testing in 3 months to confirm if it was a true positive. If the result is negative on repeat testing, I would discontinue anticoagulation. It also depends on how high the tiers of aCL antibodies were. Anything lower than 40 GPL or MPL units is insignificant and I wouldn’t anticoagulate in that case.

Yazhini Vallatharasu, MD
Appleton, WI

I think one should start the patient on anticoagulation after explaining the risk-benefit ratio and repeat testing at 12 weeks. If the patient is persistently positive for any of the three lab markers, then continue anticoagulation. If not, anticoagulation can be stopped. If the patient is young, one should also look for other causes of thrombophilia after stopping anticoagulation for at least 4 weeks.

Kaumilkumar Hasmukhlal Patel, MD
Kolkata, India

I would wait to anticoagulate until I have confirmation of LA- and aCL-positive tests, with retesting done outside of the acute phase (at least 2 months later).

Maria Cristina Pascual Izquierdo, MD, PhD
Madrid, Spain

I would recommend standard antiplatelet therapy, repeating the antiphospholipid work-up in 6-8 weeks.

Kapisthalam S. Kumar, MD
New Port Richey, FL

Stroke causes false positives on phospholipid-based tests. I would not test immediately after t-PA.

Philip C. Comp, MD, PhD
Oklahoma City, OK

I would start a low-molecular-weight heparin (LMWH), followed by warfarin, and would do serial LA and APLA testing. If tests confirm that it’s APS, I would rule out a change to antiplatelet therapy and would continue warfarin.

Tiberio Lindgren, MD
Orange, CA

I would assume it could be APS-related thrombosis, so I would anticoagulate to keep an international normalized ratio (INR) of 2-3 with vitamin K antagonists and retest for APLAs at least 12 weeks after the stroke. I would not give direct oral anticoagulants.

Gabriela N. Cesarman-Maus, MD, PhD
Mexico City, Mexico

In absence of bleeding tendency, perhaps it is better to anticoagulate with warfarin, which was shown to be superior in triple positive APS.

Mohammed Salem, MD
Medina, Saudi Arabia

I will presume that the strokes were ischemic. I think anticoagulation it is not indicated for the reasons the questioner stated. : We cannot put value in these tests because of when they were collected (acute phase). If we are talking about young patients without risk factors for atherosclerotic events, such as diabetes, obesity, dyslipidemia, or hypertension, that would raise a red flag in my mind, but I still wouldn’t initiate anticoagulation without another sign of APS. I would advise against anticoagulation and recommend a platelet antiaggregant, such as aspirin. But I would repeat the antibody tests 12 weeks after the event.

Camilla Correia, MD
Salvador, Brazil

If the patient has no other risk factors for stroke, I would anticoagulate with warfarin or enoxaparin sodium and repeat the LA test in 3 months. I would avoid rivaroxaban due to false positive LA tests. If they have hypertension or diabetes, I would use antiplatelet agents and recheck APLA tests in 3 months.

Ajay Dar, MD
Lansdowne, VA

If the stroke is very large, then I would be hesitant to start anticoagulation. I would ask the neurologist what the risk is for postinfarction bleeding. If the risk is low, then I would not hesitate to start anticoagulation. If not, I would be more conservative. I have used prophylactic doses of heparin when I am not sure whether to start a full dose of anticoagulation.

Bassam Matar, MD
Rolling Meadows, IL

I would probably not fully anticoagulate yet since they don’t meet criteria for APS. I would use standard antiplatelet therapy.

Robert John Ellis, MD
Springfield, MO

I don’t think that t-PA interferes with APAs. I believe these patients require anticoagulation.

Marion Sternbach, MD, FRCPC
Oakville, Ontario

The cases could not be labeled as APS unless you demonstrate the persistence of the antibody 12 weeks apart, according to the present guidelines. These antibodies could be transient. Regarding anticoagulation, unless there is another indication such as atrial fibrillation or venous thromboembolism, one can wait until the diagnosis is confirmed. One must risk stratify as per the antibody test. If the LA, aCL, or anti-beta2-glycoprotein tests are positive in high titer, then the risk of recurrence is high. One could consider lifelong anticoagulation, with antiplatelets. I have not come across any relationship between t-PA and LA. Plasmin is an immunosuppressant and will not lead to aberrant autoimmunity.

Abdulrahman Saifudeen, MD
Salalah, Oman

I recently received the same consult question for a case in which the stroke was small and the full APS panel was not yet available (antibody positive, but LA pending). After discussion with the neurologists, daily aspirin alone was recommended. After discussion with other local hematologists, aspirin alone and repeating the APS panel at 12 weeks seemed to be the most common approach before committing the patient to full dose anticoagulation.

Aleksandra McLeod, MD
Portland, OR

I think is necessary to start anticoagulation therapy as soon as possible. t-PA can probably affect the results of an APLA test in some circumstances.

Giulio De Rossi, MD
Rome, Italy