Abstract
For more than 10 years, direct oral anticoagulants (DOACs) have been increasingly prescribed for the prevention and treatment of thrombotic events. However, their use in immunothrombotic disorders, namely heparin-induced thrombocytopenia (HIT) and antiphospholipid syndrome (APS), is still under investigation. The prothrombotic state resulting from the autoimmune mechanism, multicellular activation, and platelet count decrease, constitutes similarities between HIT and APS. Moreover, they both share the complexity of the biological diagnosis. Current treatment of HIT firstly relies on parenteral non-heparin therapies, but DOACs have been included in American and French guidelines for a few years, providing the advantage of limiting the need for treatment monitoring. In APS, vitamin K antagonists are conversely the main treatment (+/− anti-platelet agents), and the use of DOACs is either subject to precautionary recommendations or is not recommended in severe APS. While some randomized controlled trials have been conducted regarding the use of DOACs in APS, only retrospective studies have examined HIT. In addition, vaccine-induced immune thrombotic thrombocytopenia (VITT) is now a part of immunothrombotic disorders, and guidelines have been created concerning an anticoagulant strategy in this case. This literature review aims to summarize available data on HIT, APS, and VITT treatments and define the use of DOACs in therapeutic strategies.
Highlights
We aim to summarize available data regarding the use of direct oral anticoagulants (DOACs) in immunothrombotic diseases with a focus on heparin-induced thrombocytopenia (HIT), antiphospholipid syndrome (APS), and vaccine-induced immune thrombotic thrombocytopenia (VITT)
HIT should be suspected whenever the platelet count drops by 50% or when new thrombosis occurs in a patient 5 to 14 days after beginning heparin therapy
The benefit-risk balance of DOACs has been established for preventing thrombosis in atrial fibrillation patients or for preventing recurrent ischemic events following deep vein thrombosis and pulmonary embolism (PE)
Summary
Since 2008, direct oral anticoagulants (DOACs) have been increasingly prescribed for the treatment and prevention of thromboembolic events. Their efficacy and safety are well documented for the prevention of thromboembolism events in the case of non-valvular atrial fibrillation and for the treatment and prevention of venous thromboembolism (VTE). DOACs provide advantages, including oral administration, rapid onset of anticoagulant effects, fixed doses for each indication, fewer drug interactions, and no routine laboratory monitoring. They are easier to manage than vitamin K antagonists (VKA) and parenteral anticoagulant drugs; they display a long half-life and have limited use in patients with renal or hepatic dysfunction or with altered gut absorption. We aim to summarize available data regarding the use of DOACs in immunothrombotic diseases with a focus on HIT, APS, and VITT
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