{"id":475,"date":"2024-06-23T09:32:55","date_gmt":"2024-06-23T09:32:55","guid":{"rendered":"https:\/\/guidestonefinancialgroup.com\/?p=475"},"modified":"2024-10-15T23:25:52","modified_gmt":"2024-10-15T23:25:52","slug":"the-lowdown-on-medications-and-antiphospholipid-syndrome-warfarin-enoxaparin-doacs-nsaids-more-2","status":"publish","type":"post","link":"https:\/\/guidestonefinancialgroup.com\/index.php\/2024\/06\/23\/the-lowdown-on-medications-and-antiphospholipid-syndrome-warfarin-enoxaparin-doacs-nsaids-more-2\/","title":{"rendered":"The Lowdown on Medications and Antiphospholipid Syndrome (Warfarin, Enoxaparin, DOACs, NSAIDs &amp; More)"},"content":{"rendered":"<div id=\"playht-iframe-wrapper\" style=\"max-height: 210px !important\">\n<\/div>\n<p>This article is part of the Antiphospholipid Syndrome (APS) resource library that I\u2019m building up on my site. In this post, we will focus on medications and Antiphospholipid Syndrome. In particular, warfarin is a key medication for the management of APS, especially if you\u2019ve experienced blood clotting events in the past. We will also take a look at what DOACs (direct oral anticoagulants) are, how other medications such as NSAIDs (non steroidal anti-inflammatory drugs) can interact with warfarin, and exciting new drugs in the pipeline.<\/p>\n<p>If there are specific terms or topics in this post that you were wondering about, such as injections, diet, bone health or something else, you can probably <strong><a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/\">find the answers in the complete Antiphospholipid Syndrome A \u2013 Z guide here<\/a><\/strong>!<\/p>\n<ul class=\"relatedList\">\n<u>Read Related Posts in the Antiphospholipid Syndrome Series:<\/u><\/p>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2024\/06\/02\/latest-research-on-antiphospholipid-syndrome\/\">Latest Research on Antiphospholipid Syndrome<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2024\/06\/08\/womens-health-in-antiphospholipid-syndrome\/\">Pregnancy, Miscarriage &amp; Women\u2019s Health in Antiphospholipid Syndrome<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2018\/05\/27\/living-with-antiphospholipid-syndrome-personal-experiences\/\">The Annoying Thing About Living with Antiphospholipid Syndrome (My Personal Experiences)<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2016\/04\/08\/thromboembolism-antiphospholipid-syndrome\/\">An Experience from Hell: Thromboembolism From Antiphospholipid Syndrome<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2019\/08\/08\/sgh-hospital-emergency\/\">What it Feels Like to be Refused Treatment by a Hospital\u2019s A&amp;E<\/a><\/li>\n<\/ul>\n<p><strong class=\"pinTxtCTA\">Pin to Your Medications and Antiphospholipid Syndrome Boards:<\/strong><\/p>\n<div class=\"pinBox\">\n<img decoding=\"async\" loading=\"lazy\" data-pin-description=\"Learn more about medications and Antiphospholipid Syndrome - from vitamin K antagonists like warfarin, enoxaparin, DOACs, NSAIDS and more.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"The Lowdown on Medications and Antiphospholipid Syndrome (Warfarin, Enoxaparin, DOACs, NSAIDs and More)\" width=\"683\" height=\"1024\" class=\"alignnone size-large wp-image-43168 lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/lowdown-medications-and-antiphospholipid-syndrome-warfarin-enoxaparin-doacs-nsaids-2-683x1024.jpg?strip=all&amp;lossy=1&amp;ssl=1\">\n<\/div>\n<p><em>*Disclaimer: This article is meant for educational purposes, and is based on my personal experiences as a patient. Whilst I have done my utmost to be meticulous in research, <strong>I am not a doctor, and nothing in this article should be substituted for medical advice.<\/strong> Please consult your own doctor before changing or adding <strong>any<\/strong> new treatment protocols. This post may also contain affiliate links. It will cost you nothing to click on them. I will get a small referral fee from purchases you make, which helps with the maintenance of this blog. Read our <a href=\"https:\/\/www.achronicvoice.com\/privacy-policy\/\">Privacy Policy page<\/a> for more information. Thank you!<\/em><\/p>\n<h2 id=\"intro\"><strong>A Brief Introduction to Vitamin K<\/strong><\/h2>\n<p><a href=\"https:\/\/ods.od.nih.gov\/factsheets\/VitaminK-HealthProfessional\/\" rel=\"noopener\" target=\"_blank\">Vitamin K<\/a> is important to know all about as a patient with Antiphospholipid Syndrome, as it interacts with warfarin and is a key contributor to the blood clotting process. It is a fat-soluble vitamin that comes in the form of vitamin K1 (phylloquinone) and vitamin K2 (a series of menaquinones). There is also a synthetic form \u2013 Vitamin K3 (menadione), which is no longer used in dietary supplements as they have been found to damage hepatic cells (Office of Dietary Supplements, 29 March, 2021).<\/p>\n<p>Vitamin K1 is the main form of vitamin K in the human diet, and can mostly be found in green, leafy vegetables, certain fruits, and its absorption is increased in the presence of butter or oils. Vitamin K2 is mainly derived from fermented foods, dairy produce and animal-based sources.<\/p>\n<p><a href=\"https:\/\/www.mdpi.com\/1422-0067\/20\/4\/896\" rel=\"noopener\" target=\"_blank\">According to Halder et al. (2019)<\/a>:<\/p>\n<blockquote>\n<p>\u201cVKDPs [vitamin K-dependent proteins] are categorized as hepatic and extra-hepatic VKDPs. Hepatic VKDPs include coagulation factors II, VII, IX, X, and anticoagulant protein C, protein S, and protein Z, all of which are involved in regulating blood coagulation. Extra-hepatic VKDPs include Matrix Gla protein (MGP), Osteocalcin, and Gla-rich protein (GRP). These VKDPs are primarily involved in maintaining bone homeostasis, as well as inhibiting ectopic calcification.\u201d<\/p>\n<\/blockquote>\n<p>In basic terms, what this means is that vitamin K, whether in K1 or K2 form, is an essential component of blood clotting processes, maintenance of bone health, and prevention of vessel mineralisation, depending on how and where they are metabolised. Whilst it\u2019s important to be aware of vitamin K, I won\u2019t deep dive into it in this post as I\u2019d like to focus on medications and Antiphospholipid Syndrome.<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#coagulation\">Coagulation<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#fruits\">Fruits<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#LeafyVeg\">Green, Leafy Vegetables<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#SectionK\">Vitamin K<\/a><\/div>\n<ul class=\"relatedList\">\n<u>Read Related Posts:<\/u><\/p>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2021\/06\/18\/vitamin-d-vitamin-k2\/\">Vitamin D &amp; Vitamin K2: How They Boost Each Other in the Body<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2021\/05\/02\/malabsorption-nutrients\/\">The Causes &amp; Dangers of Malabsorption &amp; An Easy Way to Get Your Nutrients<\/a><\/li>\n<\/ul>\n<h2 id=\"VKAs\"><strong>Vitamin K Antagonists (VKAs)<\/strong><\/h2>\n<p>Vitamin K antagonists (VKAs) are a class of medications used for the treatment and prevention of thrombosis. The most well-known and commonly used VKA is warfarin. For the sake of interest, <a href=\"https:\/\/www.sciencedirect.com\/topics\/pharmacology-toxicology-and-pharmaceutical-science\/ethyl-biscoumacetate\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">other types of VKAs<\/a> include: ethyl biscoumacetate, phenindione, anisindione, dicoumarol, phenprocoumon and diphenadione. There is a reason why warfarin is the most commonly used, as many of these other VKAs are erratic, highly toxic, or can cause other adverse side effects (Vardanyan and Hruby, 2006).<\/p>\n<p>The administration of VKAs is convenient and practical, as they can be taken orally, and have a long half-life (warfarin has a half-life of 36 \u2013 42 hours). Doctors are also able to adjust dosages for more precision in individual patients as needed, based on risk factors and medical history. <a href=\"https:\/\/thrombosisjournal.biomedcentral.com\/articles\/10.1186\/s12959-016-0088-y\" rel=\"noopener\" target=\"_blank\">VKAs work by antagonising the enzyme vitamin K epoxide reductase (VKOR)<\/a> to prevent vitamin K from being recycled. This results in inhibition of the coagulation cascade, as many clotting factors rely on vitamin K to synthesise (Schein et al., 2016).<\/p>\n<h3 id=\"coumarins\">Coumarins<\/h3>\n<p>Vitamin K antagonists such as warfarin, acenocoumarol and phenprocoumon are <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7146486\/\" rel=\"noopener\" target=\"_blank\">derivatives of coumarin<\/a>, which can be of natural or synthetic origin. In 1945, Karl Link experimented with 150 naturally occurring coumarin derivatives, before concluding that one compound was particularly active \u2013 warfarin. For a rare subset of patients with mutations in VKOR, VKAs are unfortunately low in efficacy or ineffective due to coumarin resistance (Kasperkiewicz et al., 2020). <strong><a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#coumarin\">Read more about coumarins in the A to Z APS resource guide here<\/a>.<\/strong><\/p>\n<h2 id=\"warfarin\"><strong>Warfarin \u2013 THE Medication for Antiphospholipid Syndrome<\/strong><\/h2>\n<p>Warfarin is a vitamin K antagonist, and is probably the most important drug for the management of Antiphospholipid Syndrome, and for the prevention of thrombosis. There are two brands of warfarin available \u2013 <a href=\"https:\/\/www.healthywa.wa.gov.au\/Articles\/U_Z\/Warfarin\" rel=\"noopener\" target=\"_blank\">Coumadin and Marevan<\/a>. <strong><em>It is important to stick to the same brand, as the formulation is not an exact match<\/em><\/strong>. What that means is that the anticoagulation effects can vary between each brand, and might mess your INR up. Do discuss with your doctor first, should you need to switch brands for any reason.<\/p>\n<p>(Not so) fun fact: <a href=\"https:\/\/onlinelibrary.wiley.com\/doi\/abs\/10.1002\/ps.2780430112\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">Warfarin also first started out as rat poison<\/a>, but has declined in usage for such purposes due to an increase in resistance from these rodents, which is inheritable (Thijssen, 1995).<\/p>\n<h3 id=\"WarfarinMechanism\">How Warfarin Works to Prevent Blood Clotting<\/h3>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK441964\/\" rel=\"noopener\" target=\"_blank\">Warfarin<\/a> inhibits vitamin K dependent clotting factors II, VII, IX, and X, and also the anticoagulant proteins C and S (Crader et al., 1 May, 2023). This means that it inhibits multiple pathways in the blood clotting process, as compared to DOACs, which only disrupt a specific point. Specifically, prothrombin, FVII, FIX, protein C, and protein S are <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6714837\/\" rel=\"noopener\" target=\"_blank\">strictly related to blood coagulation processes<\/a> (Girolami et al., 2018). Approximately 10% \u2013 40% of factors II, VII, IX and X are <a href=\"https:\/\/www.nature.com\/articles\/6500220\" rel=\"noopener\" target=\"_blank\">inhibited by warfarin<\/a> (Wadelius et al., 2004).<\/p>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK507850\/\" rel=\"noopener\" target=\"_blank\">Vitamin K \u2018activates\u2019 these clotting factors via the enzyme, epoxide reductase<\/a>, which is inhibited by warfarin. In rare cases, patients who are first taking warfarin may experience warfarin-induced skin necrosis. This is especially true for patients who are deficient in protein C, as it has the shortest half-life amongst them all. In such cases, patients are often co-administered heparin, as it has a quicker effect (Barmore et al., 24 February, 2023).<\/p>\n<h3 id=\"WarfarinMetabolism\">How Warfarin is Metabolised<\/h3>\n<p>Warfarin is a potent anticoagulant that is well absorbed by the body via the intestine with 90% bioavailability, and also offers high water solubility. <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK470313\/\" rel=\"noopener\" target=\"_blank\">It is then metabolised in the liver (hepatic)<\/a>, primarily through the CYP2C9 enzyme, with a half-life of approximately 20 \u2013 60 hours. Other minor enzymatic pathways for metabolism include: CYP2C8, 2C18, 2C19, 1A2, and 3A4. How much of the drug gets metabolised is also dependent on each individual\u2019s genetic variations (Patel et al.,  24 March, 2023; Kasperkiewicz et al., 2020).<\/p>\n<p>The warfarin molecule is further broken down into two forms \u2013 S- and R-warfarin, with S-warfarin 3 \u2013 5 times more potent than R-warfarin. They are mainly broken down in the liver; metabolism of active S-warfarin is mainly via the CYP2C9 enzyme, and CYP enzymes CYP1A2 and CYP3A for R-warfarin. <\/p>\n<h3 id=\"WarfarinInteractions\">Does Warfarin Interact with Other Medications?<\/h3>\n<p>The issue with warfarin is that it is also highly bound to serum albumin, which when combined with cytochrome P450 (CYP) metabolism, <a href=\"https:\/\/link.springer.com\/chapter\/10.1007\/978-1-908517-96-8_1\" rel=\"noopener\" target=\"_blank\">interacts with many drugs and foods<\/a>. This results in warfarin either becoming more or less potent \u2013 thus increasing or decreasing its anticoagulatory effects, which can be risky either way for a patient with Antiphospholipid Syndrome (Tay et al., 2013).<\/p>\n<p>Some drugs that interact with the CYP450 2C9 are cardiovascular medications such as amiodarone, and anti-infectives such as fluconazole. Some drugs that interact with CYP1A2 or CYP3A4 are quinolones and macrolides (bactericidal antibiotics). Inhibition of these enzymes can enhance the effects of warfarin, thus increasing the risk for bleeding further. Other drugs such as rifampicin (an antibiotic), carbamazepine (an anticonvulsant) and azathioprine (a DMARD) on the other hand, induces these enzymes and can decrease the potency of warfarin (Tay et al., 2013).<\/p>\n<h4><strong>Highly Probable to Highly Improbable Interactions<\/strong><\/h4>\n<p>In a systematic review by Holbrook et al. (2005), they categorise drugs that might potentially interact with warfarin from level 1 (highly probable) to level 4 (highly improbable). <a href=\"https:\/\/jamanetwork.com\/journals\/jamainternalmedicine\/article-abstract\/486574\" rel=\"noopener\" target=\"_blank\">According to Holbrook et al. (2005)<\/a>:<\/p>\n<blockquote>\n<p>\u201cOf all 184 reviewed reports, 128 (70%) described a potentiation of warfarin\u2019s effect, while inhibition and \u201cno effect\u201d reports each comprised 28 (15%). There were 34 reports of a major interaction\u20143 case reports of thrombosis associated with trazodone, sulfasalazine, and propofol and 31 case reports describing a major potentiation.\u201d<\/p>\n<\/blockquote>\n<p>Some drugs also yielded conflicting evidence for interaction with warfarin, i.e. terbinafine, ritonavir, and influenza vaccine. <a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0268960X13000155\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">Linkins (2013) breaks down these medication categories<\/a> by Holbrook et al. (2005) into a table according to type \u2013 antibiotics, antifungals, cardiovascular, cholesterol lowering agents, analgesics or antiinflammatory agents, and others. This is definitely not an exhaustive list of medications that interact with warfarin \u2013 there are way too many to be listed in one post, plus many others whose interactions are yet unknown.<\/p>\n<h3>What if I Have No Choice but to Take a Medication That Interacts with Warfarin?<\/h3>\n<p>Sometimes, taking medications that interact with warfarin is unavoidable, such as antibiotics for an infection, or an essential drug for another medical condition. For example, I was on carbamazepine and azathioprine for a period of time in the past, in a bid to control my epilepsy and Lupus (SLE) activity.<\/p>\n<p>First, your rheumatologist (or doctor who manages your warfarin and Antiphospholipid Syndrome) should be consulted. They will then monitor and adjust your warfarin dose as needed, in combination with the other medications. As the medications I took were on a daily basis, that makes things easier as the main strategy to maintaining your target INR range is consistency in medication and food intake.<\/p>\n<p>I eventually had to stop taking those medications not because they interacted with warfarin, but because they were ineffective or unsuitable for me for various reasons. Your doctor will also work with you to retitrate your warfarin dose when and if you need to stop taking these other medications. Remember that this applies to major dietary changes as well.<\/p>\n<p>The main takeaway that I\u2019d like to highlight is to always inform and work with your doctor when introducing a new medication that might potentially interfere with warfarin. Another important point is to always state that you\u2019re on warfarin when you visit any new healthcare professional, including (especially) at the A&amp;E\/ER. In fact, you should have received a medical card that states that you are on warfarin \u2013 laminate this and keep it with you at all times so that you can show it to them.<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#SectionL\">Lupus (SLE) &amp; APS<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#genes\">Genes<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#infections\">Infections<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#injections\">Injections<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#INR\">INR<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#MedID\">Medical ID<\/a><\/div>\n<ul class=\"relatedList\">\n<u>Read Related Posts:<\/u><\/p>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2023\/11\/26\/top-tips-travelling-chronic-illness-disability\/\">Top Tips for Travelling with Chronic Illness &amp; Disability (From a Girl Who Loves to Travel)<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2022\/07\/26\/recovery-time-simultaneous-bilateral-patellar-tendon-rupture-lupus-steroids\/\">My Recovery Time for Simultaneous Bilateral Patellar Tendon Rupture (With Lupus &amp; Steroid Treatment)<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2016\/01\/19\/tonic-clonic-seizure\/\">So This is What a Tonic Clonic Seizure Feels Like<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2019\/04\/07\/dengue-fever-lupus\/\">\u201cBut That\u2019s Normal for Me\u201d (Why I Mistook Dengue Fever for a Lupus Flare)<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2020\/05\/31\/chronic-illness-life-lessons-accident-bird\/\">A Car Accident &amp; A Song Gone Silent (How Life Lessons from Chronic Illness Tide Me Through)<\/a><\/li>\n<\/ul>\n<h3 id=\"CheckWarfarin\">How to Check for Warfarin Interaction with Other Medications<\/h3>\n<p>Often, it can be a hassle and impractical to consult your doctor every time you need to take a new medication or food product. I personally use the <a href=\"https:\/\/www.medscape.com\/public\/medscapeapp\" rel=\"noopener\" target=\"_blank\">MedScape app on my phone<\/a> to do a quick check for medication interactions on the fly (I\u2019ve seen doctors use it as well!). It tells you if there are minor or major contraindications, and why. It\u2019s especially handy when I\u2019m travelling. You can also tap into its comprehensive database to learn more about any other medication.<\/p>\n<p>They also have a <a href=\"https:\/\/reference.medscape.com\/drug-interactionchecker\" rel=\"noopener\" target=\"_blank\">browser version here<\/a> that you can use, plus <a href=\"https:\/\/reference.medscape.com\/\" rel=\"noopener\" target=\"_blank\">other educational tools and resources<\/a> on their website. Do note that it\u2019s still important to cross-check with other verified sources and your doctor whenever possible, as not everything may be 100% accurate \u2013 that is impossible as research can sometimes be conflicting, and is also being constantly updated with new discoveries. (You can <strong><a href=\"https:\/\/www.achronicvoice.com\/2024\/06\/02\/latest-research-on-antiphospholipid-syndrome\/\">check out the latest research on Antiphospholipid Syndrome in this post<\/a>.<\/strong>)<\/p>\n<p><strong class=\"pinTxtCTA\">Screenshot Examples of the MedScape App:<\/strong><\/p>\n<div class=\"tripleColHolder\">\n<img decoding=\"async\" loading=\"lazy\" data-pin-description=\"MedScape mobile app - Warfarin medication information\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"MedScape mobile app - Warfarin medication information\" width=\"473\" height=\"1024\" class=\"alignnone size-large wp-image-43147 thirdCol lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/medscape-warfarin-screenshot-1-473x1024.jpg?strip=all&amp;lossy=1&amp;ssl=1\"><\/p>\n<p><img decoding=\"async\" loading=\"lazy\" data-pin-description=\"MedScape mobile app - Warfarin, azathioprine and carbamazepine medication interaction example.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"MedScape mobile app - Warfarin, azathioprine and carbamazepine medication interaction example.\" width=\"473\" height=\"1024\" class=\"alignnone size-large wp-image-43146 thirdCol lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/medscape-warfarin-screenshot-2-473x1024.jpg?strip=all&amp;lossy=1&amp;ssl=1\"><\/p>\n<p><img decoding=\"async\" loading=\"lazy\" data-pin-description=\"MedScape mobile app - Warfarin interactions with other medications.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"MedScape mobile app - Warfarin interactions with other medications.\" width=\"473\" height=\"1024\" class=\"alignnone size-large wp-image-43145 thirdCol lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/medscape-warfarin-screenshot-3-473x1024.jpg?strip=all&amp;lossy=1&amp;ssl=1\">\n<\/p>\n<\/div>\n<h3 id=\"WarfarinAmount\">How Much Warfarin Do I Need to Take with Antiphospholipid Syndrome?<\/h3>\n<p>The dose requirement of warfarin varies more than 10-fold amongst patients, due to genetic polymorphisms of CYP2C9, dietary differences, and other factors. <a href=\"https:\/\/www.nature.com\/articles\/6500182\" rel=\"noopener\" target=\"_blank\">According to Takahashi and Echizen (2003)<\/a>:<\/p>\n<blockquote>\n<p>\u201cTherapeutic targets measured by international normalized ratio (INR) of prothrombin time appear to differ between populations: INR of 2\u20133 for most indications in Caucasian patients<sup>1<\/sup> and 1.5\u20132.5 for Asian patients.\u201d<\/p>\n<\/blockquote>\n<p>And <a href=\"https:\/\/www.nature.com\/articles\/6500220\" rel=\"noopener\" target=\"_blank\">according to Wadelius et al. (2004)<\/a>:<\/p>\n<blockquote>\n<p>\u201cCYP2C9 variants, age, weight, concurrent drug treatment and indication for treatment significantly influenced warfarin dosing in these patients, explaining 29% of the variation in dose. CYP3A5 did not affect warfarin dosing.\u201d<\/p>\n<\/blockquote>\n<p>Thus, there is no hard and fast rule as to how much warfarin one should take, as that needs to be titrated on an individual basis. Apart from the diverse genetic and dietary differences amongst patients, other factors need to be taken into account as well, such as comorbidities and the medications used to treat them, medical history, and other risk factors. If you\u2019ve had had a thrombosis in the past, your INR target range might need to be higher as well, as that is an indication of an increased risk for blood clotting.<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#AfricanAmericans\">African Americans<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#asians\">Asians<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#caucasians\">Caucasians<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#chinese\">Chinese Patients<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#CYP2C9\">CYP2C9 Gene<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#genes\">Genes<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#INR\">INR<\/a>\n<\/div>\n<p><strong class=\"pinTxtCTA\">Pin to Your Warfarin, Medications and Antiphospholipid Syndrome Boards:<\/strong><\/p>\n<div class=\"pinBox\">\n<img decoding=\"async\" loading=\"lazy\" data-pin-description=\"Read the Antiphospholipid Syndrome guide on warfarin medication interactions. Learn more about all the other medications used for the management of APS as well.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"Antiphospholipid Syndrome Guide - Warfarin Medication Interactions\" width=\"683\" height=\"1024\" class=\"alignnone size-large wp-image-43165 lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/antiphospholipid-syndrome-guide-warfarin-medication-interactions-1-683x1024.jpg?strip=all&amp;lossy=1&amp;ssl=1\">\n<\/div>\n<h3 id=\"tecarfarin\">Tecarfarin \u2013 A Novel Vitamin K Antagonist in Phase III Trials<\/h3>\n<p>Tecarfarin is a novel VKA with a structural analog of warfarin, and can be measured via INR just like warfarin. It is being developed by <a href=\"https:\/\/www.cadrenal.com\/\" rel=\"noopener\" target=\"_blank\">Cardrenal Therapeutics<\/a> for patients with implanted medical devices, end-stage renal disease (ESRD) and atrial fibrillation (AFib), although they are looking to expand its scope to <a href=\"https:\/\/www.sec.gov\/Archives\/edgar\/data\/1937993\/000121390023084969\/ea187953ex99-1_cadrenal.htm\" target=\"_blank\" rel=\"noopener\" class=\"broken_link\">include other patients who require anticoagulation<\/a> too, such as in APS.<\/p>\n<p> It has <a href=\"https:\/\/www.cadrenal.com\/tecarfarin\/\" rel=\"noopener\" target=\"_blank\">orphan drug with fast track designation<\/a> from the FDA \u2013 meaning to say that it has governmental support for its development as a pharmaceutical agent for rare diseases. It is currently in Phase III clinical trials and in fact, since the time I drafted this section, it has already <a href=\"https:\/\/www.cadrenal.com\/investors\/press-releases\/detail\/cadrenal-therapeutics-provides-third-quarter-2023-corporate-update\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">completed the ARIES-HM3 trial<\/a> and presented its findings at the International Society for Heart &amp; Lung Transplantation (ISHLT) 44th Annual Meeting &amp; Scientific Sessions on June 3, 2024.<\/p>\n<p>There are over hundreds of medications and foods that warfarin can interact with, due to the way it is metabolised by CYP2C9. Genetic variability in CYP2C9 gene can also affect the instability of INR. <a href=\"https:\/\/www.thieme-connect.com\/products\/ejournals\/abstract\/10.1160\/TH16-08-0623\" target=\"_blank\" rel=\"noopener\">Tecarfarin on the other hand is metabolised by hCE-2<\/a>, a pathway with no significant drug interactions, or genetic variability (Albrecht et al., 2017). It however, does not display any advantages over warfarin for people with VKORC1 polymorphisms.<\/p>\n<p>In a <a href=\"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/CIRCULATIONAHA.109.856120\" target=\"_blank\" rel=\"noopener\" class=\"broken_link\">multicentre study of 66 AFib patients<\/a> for up to 12 weeks in a phase IIA trial, tecarfarin was shown to be well-tolerated without any adverse effects (Ellis et al., 2009). It was also shown to be well-tolerated in a small <a href=\"https:\/\/link.springer.com\/article\/10.1007\/s40256-022-00562-5\" target=\"_blank\" rel=\"noopener\">study of 40 healthy Chinese volunteers<\/a> in a phase I trial (Zhou et al., 2023).<\/p>\n<p>This means that tecarfarin might be a potential warfarin alternative or even replacement in future, as research has shown thus far similar effects as warfarin, minus the many interactions with other foods and drugs. I guess only time will tell, after it jumps through all the hoops of the essential clinical trials! (You can <strong><a href=\"https:\/\/www.achronicvoice.com\/2024\/06\/02\/latest-research-on-antiphospholipid-syndrome\/\">check out the latest research in this post<\/a>.<\/strong>)<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#CYP2C9\">CYP2C9 Gene<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#diet\">Diet<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#genes\">Genes<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#herbs\">Herbs<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#saponins\">Saponins<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#vegetables\">Vegetables<\/a>\n<\/div>\n<h2 id=\"enoxaparin\"><strong>Enoxaparin \u2013 Another Important Medication in the APS Treatment Arsenal<\/strong><\/h2>\n<p>We\u2019ve covered quite a bit on warfarin, because it is so important when it comes to medications and Antiphospholipid Syndrome. Another important drug is enoxaparin (<a href=\"https:\/\/www.drugs.com\/ingredient\/enoxaparin.html\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">brand names: Lovenox and Clexane)<\/a>, which is also known as a \u201clow molecular weight heparin\u201d (LMWH). Two other <a href=\"https:\/\/www.fda.gov\/drugs\/postmarket-drug-safety-information-patients-and-providers\/generic-enoxaparin-questions-and-answers\" rel=\"noopener\" target=\"_blank\">FDA approved LMWHs in the USA<\/a> are dalteparin (Fragmin) and tinzaparin (Innohep). Note that they should not be used interchangeably.<\/p>\n<p>Enoxaparin is a medication that\u2019s commonly substituted for warfarin, when APS patients need to pause their warfarin intake for whatever reason. It is often used as a bridge medication between surgical operations, where there is a higher chance of excessive bleeding.<\/p>\n<p>This does not only include major surgeries, but also minor ones such as dental procedures, implantation of contraceptive devices, and procedures that require intramuscular injections such as the HPV vaccine. Enoxaparin has a quicker onset as compared to warfarin, and only has <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3324206\/\" rel=\"noopener\" target=\"_blank\">a half-life of about 4.5 \u2013 7 hours<\/a> (Cook, 2010). Hence, it is safer to be on enoxaparin during periods where excessive bleeding might be anticipated. You will need to do a warfarin reversal when switching to enoxaparin, which your doctor and gynaecologist will guide you through.<\/p>\n<p>&lt;!&#8211;You will need to do a warfarin reversal when switching to enoxaparin, which you can <strong style=\"color:red\">learn more about in the A &#8211; Z APS Resource Guide here<\/strong>.&#8211;&gt;<\/p>\n<p><a href=\"https:\/\/www.fda.gov\/drugs\/postmarket-drug-safety-information-patients-and-providers\/generic-enoxaparin-questions-and-answers\" rel=\"noopener\" target=\"_blank\">Whilst derived from heparin, the final formulation of enoxaparin is different<\/a>. It has a <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK539865\/\" rel=\"noopener\" target=\"_blank\">bioavailability of 90% when given in the subcutaneous form<\/a> (injection into the fat just under the skin), and is a more stable and predictable drug that can be self-administered by patients at home (Jupalli and Iqbal, 28 August, 2023). Pregnant women with APS generally need to substitute warfarin for enoxaparin\/LMWH during the term of their pregnancy, as warfarin can be harmful to foetuses. You can <strong><a href=\"https:\/\/www.achronicvoice.com\/2024\/06\/08\/womens-health-in-antiphospholipid-syndrome\/#pregnancy\">read more about pregnancy with Antiphospholipid Syndrome here<\/a>.<\/strong><\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#bleeding\">Bleeding<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#injections\">Injections<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#surgery\">Surgery<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#vaccinations\">Vaccinations<\/a>\n<\/div>\n<h3 id=\"EnoxaparinWork\">How Does Enoxaparin \/ LMWH Work?<\/h3>\n<p><a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/B9781416062080100783\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">According to Lawrence (2011)<\/a>:<\/p>\n<blockquote>\n<p>\u201c[LMWHs and fondaparinux] target anti\u2013factor Xa activity rather than AT [antithrombin]. With LMWH and fondaparinux, there is a reduced risk of heparin-induced thrombocytopenia (HIT), and monitoring of the aPTT is also not required, because the aPTT is insensitive to alterations in factor Xa.\u201d<\/p>\n<\/blockquote>\n<p>This means that the anticoagulatory mechanisms of LMWH differs from that of vitamin K antagonists, and that patients do not need to measure their INR like they do when on warfarin. I actually prefer being on enoxaparin as compared to warfarin despite the hassle of injections, because it gives me a chance to indulge in all the foods I love (yes, like broccoli and tofu\u2026), as it does not interact with foods in the same way as VKAs do. Sadly, enoxaparin is not a good long-term medication as it is known to <a href=\"https:\/\/link.springer.com\/article\/10.1007\/s00774-021-01268-5\" rel=\"noopener\" target=\"_blank\">impair bone health and bone healing<\/a> (Li et al., 2022). You can <strong><a href=\"https:\/\/www.achronicvoice.com\/2024\/07\/02\/how-does-antiphospholipid-syndrome-affect-the-body-blood-major-organs\/#musculoskeletal\">learn more about musculoskeletal manifestations in APS here<\/a>.<\/strong><\/p>\n<p>Having said that, that does not mean that there are no drug interactions with enoxaparin. <a href=\"https:\/\/www.mayoclinic.org\/drugs-supplements\/enoxaparin-intravenous-route-subcutaneous-route-injection-route\/side-effects\/drg-20063670?p=1\" rel=\"noopener\" target=\"_blank\">Mayo Clinic has listed some medications that can interact with enoxaparin here<\/a>, and also certain medical conditions that should be highlighted to your doctor if you have them.<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#broccoli\">Broccoli<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#injections\">Injections<\/a>\n<\/div>\n<h2 id=\"HeparinVsLMWH\"><strong>Differences Between \u2018Standard\u2019 Heparin and Low Molecular Weight Heparin<\/strong><\/h2>\n<p>It is easy to get confused between enoxaparin\/LMWH and heparin, since technically enoxaparin is derived from heparin. Many patients and sometimes even doctors refer to enoxaparin as heparin in casual speech. However, whilst enoxaparin can be self-administered by the patient via subcutaneous injections, unfractionated heparin (UFH) is usually given intravenously within a hospital setting, as there is a risk of <a href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S2352556820300448\" rel=\"noopener\" target=\"_blank\">Heparin Induced Thrombocytopenia<\/a> (HIT).<\/p>\n<p>HIT is a life-threatening condition where massive activation of platelets take place, with multi-cellular release of micro particles that contribute to hypercoagulability (Gruel et al., 2020). Compared to LMWH, unfractionated heparin is a highly variable drug as well, where almost 75% of patients fail to achieve the intended aPTT. Hence, patients need to be closely monitored when on unfractionated heparin (Krishnaswamy et al., 2010).<\/p>\n<p><a href=\"https:\/\/journals.lww.com\/critpathcardio\/abstract\/2010\/03000\/the_use_and_limitations_of_unfractionated_heparin.7.aspx\" rel=\"noopener\" target=\"_blank\">According to Krishnaswamy et al. (2010)<\/a>:<\/p>\n<blockquote>\n<p>\u201cUnfractionated heparin (UFH) exerts its effect by binding and inducing a conformational change in antithrombin (AT), converting AT to a more efficient inhibitor of circulating thrombin (factor IIa), factor Xa, factor IXa, factor XIIa, and kallikrein. Contributing to its efficiency, heparin can dissociate from the thrombin: AT complex and catalyze the activity of other AT molecules.\u201d<\/p>\n<\/blockquote>\n<p>Referring back to Lawrence\u2019s (2011) explanation of the mechanisms of LMWHs, in comparison unfractionated heparin readily binds to antithrombin as well. This makes unfractionated heparin a more potent anticoagulant as compared to LMWH \u2013 but also brings with it more complications and bleeding risks. It is still an important medication to combat acute cases and medical emergencies however, such as pulmonary embolisms and heart attacks.<\/p>\n<p><strong><a href=\"https:\/\/www.achronicvoice.com\/2024\/07\/02\/how-does-antiphospholipid-syndrome-affect-the-body-blood-major-organs\/\">Learn more about pulmonary and cardiovascular manifestations in APS, and also more about thrombocytopenia in this post<\/a>.<\/strong><\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#coagulation\">Coagulation<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#platelets\">Platelets<\/a>\n<\/div>\n<p><strong class=\"pinTxtCTA\">Pin to Your Medications and Antiphospholipid Syndrome Boards:<\/strong><\/p>\n<div class=\"pinBox\">\n<img decoding=\"async\" loading=\"lazy\" data-pin-description=\"Read more about the medications that are important in the management of Antiphospholipid Syndrome, such as warfarin and enoxaparin\/LMWH. Also learn more about DOACs, and other medications that can interfere with warfarin, such as NSAIDs.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"Medications and Antiphospholipid Syndrome - What You Need to Know\" width=\"683\" height=\"1024\" class=\"alignnone size-large wp-image-43169 lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/medications-and-antiphospholipid-syndrome-need-know-683x1024.jpg?strip=all&amp;lossy=1&amp;ssl=1\">\n<\/div>\n<h2 id=\"DOACs\"><strong>DOACs &amp; Antiphospholipid Syndrome<\/strong><\/h2>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC9638657\/\" rel=\"noopener\" target=\"_blank\">DOACs stands for \u2018Direct Oral Anticoagulants\u2019<\/a>, and they can be categorised into these main classifications: oral direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban, and betrixaban), and direct thrombin inhibitors (i.e. dabigatran) (Nasiri et al., 2022).<\/p>\n<p>You can actually skip this entire section with a main takeaway \u2013 warfarin is still the mainstay drug for patients with Antiphospholipid Syndrome, especially for those who are high risk, or who have had a thrombosis before. However knowing me, I went down the research rabbit hole and found a lot of interesting information about these anticoagulants. I\u2019ve actually asked my own rheumatologist before why I can\u2019t be on DOACs as opposed to warfarin, as their benefits seemed much better. Now I know clearly why. If you\u2019re interested to learn how DOACs work as an anticoagulant and why they aren\u2019t quite recommended for APS patients, then read on!<\/p>\n<h3 id=\"WhatDOACs\">What are DOACs and How do They Work?<\/h3>\n<p><a href=\"https:\/\/thrombosis.org\/2020\/11\/doacs-vs-warfarin\/\" rel=\"noopener\" target=\"_blank\">DOACs are anticoagulants like VKAs<\/a>, but their mechanism differs. The <a href=\"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2021.715878\/full\" rel=\"noopener\" target=\"_blank\">main advantages<\/a> are that patients who are on DOACs need not monitor their diet or INR, and they have a rapid onset and offset of action (Pastori et al., 2021). One interesting finding about DOACs is that beyond their anticoagulation properties, they may also have an anti-inflammatory, anti-fibrotic and anti-angiogenic properties (Signorelli et al., 2018).<\/p>\n<p>That might sound great, but <a href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S2387020623002802\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">APS patients are advised to use VKAs<\/a> such as warfarin instead, especially if you\u2019ve had a history of arterial thrombosis, or are triple positive, or even maybe double positive for antiphospholipid antibodies (Gir\u00f3n-Ortega and Gir\u00f3n-Gonz\u00e1lez, 2023; also see <a href=\"https:\/\/www.jacc.org\/doi\/abs\/10.1016\/j.jacc.2023.10.038\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">Bejjani et al., 2024<\/a>). <strong><a href=\"https:\/\/www.achronicvoice.com\/2016\/04\/08\/thromboembolism-antiphospholipid-syndrome\/\">I personally have had multiple DVTs and a PE before<\/a><\/strong>, so my target INR with warfarin needs to be higher than the average APS patient, as I am at a greater risk of clotting. That can be better achieved via VKAs as compared to DOACs.<\/p>\n<p>VKAs also target all phases of thrombin generation, whereas DOACs target only the initiation and\/or propagation process. Rivaroxaban and apixaban in particular were found to be significantly inferior to VKAs for the prevention of recurrent thrombosis in APS patients (Gir\u00f3n-Ortega and Gir\u00f3n-Gonz\u00e1lez, 2023). <a href=\"https:\/\/journals.lww.com\/annals-of-medicine-and-surgery\/fulltext\/2023\/07000\/direct_oral_anticoagulants_vs__vitamin_k.47.aspx\" rel=\"noopener\" target=\"_blank\">DOACs also showed an increased risk of stroke amongst APS patients<\/a>, and they may also be at a higher risk of thrombotic events (Shah et al., 2023).<\/p>\n<p>Another problem with DOACs is that not all of them have an antidote at present, and more studies are yet to be done as to their safety and efficacy in actual patients. There are also <a href=\"https:\/\/onlinelibrary.wiley.com\/doi\/full\/10.1111\/imj.12448\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">specific groups of individuals whom DOACs are not suitable for<\/a>, such as those with poor renal function, who have a prosthetic heart valve, a disorder of haemostasis, amongst others (Tran et al., 2014).<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#diet\">Diet<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#INR\">INR<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#NCAPS\">Non-Criteria\/Seronegative APS<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#PAPS\">Primary APS<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#SAPS\">Secondary APS<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#TriplePos\">Triple Positive<\/a>\n<\/div>\n<h3 id=\"thrombin\">What is Thrombin?<\/h3>\n<p>A blood clot is also known as a thrombus, and thrombin plays an important role in the blood clotting process. Thrombin converts fibrinogen to fibrin, which is a tough protein that forms blood clots to seal wound sites. Thrombin is also the most potent platelet agonist (i.e. clots the blood). The more technical explanation, <a href=\"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/ATVBAHA.118.311655\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">according to Posma et al. (2019)<\/a>:<\/p>\n<blockquote>\n<p>\u201cActivation of the blood coagulation cascade leads to fibrin deposition and platelet activation that are required for hemostasis. However, aberrant activation of coagulation can lead to thrombosis. Thrombi can cause tissue ischemia, and fibrin degradation products and activated platelets can enhance inflammation.\u201d<\/p>\n<\/blockquote>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#BloodClots\">Blood Clots<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#coagulation\">Coagulation<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#embolus\">Embolus<\/a>\n<\/div>\n<h2 id=\"DTIs\"><strong>DOACs: Direct Thrombin Inhibitors (DTIs)<\/strong><\/h2>\n<p><a href=\"https:\/\/www.annualreviews.org\/content\/journals\/10.1146\/annurev-med-062209-095159\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">According to Eriksson et al. (2011)<\/a>:<\/p>\n<blockquote>\n<p>\u201cDTIs directly neutralize thrombin by occupying the catalytic binding site, fibrinogen binding site, or both. DTIs also inhibit both fluid-phase and fibrin-bound thrombin.\u201d<\/p>\n<\/blockquote>\n<p>They do pretty much what their name states \u2013 inhibition of thrombin, which results in a reduction of blood clotting. A <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3195735\/\" rel=\"noopener\" target=\"_blank\">key advantage of DTIs<\/a> is their ability to bind directly to thrombin, and they do not bind to other plasma proteins either (Lee and Ansell, 2011).<\/p>\n<h3 id=\"dabigatran\">Dabigatran \u2013 The Only Approved DTI<\/h3>\n<p>The only approved DTI for use at present is <a href=\"https:\/\/www.frontiersin.org\/journals\/pharmacology\/articles\/10.3389\/fphar.2013.00012\/full\" rel=\"noopener\" target=\"_blank\">dabigatran etexilate<\/a>, which is a prodrug that metabolises into dabigatran in the body. Other DTIs such as ximelagatran have been withdrawn due to hepatotoxicity reports (Posma et al., 2019; van Ryn et al., 2013). Dabigatran is approved in over 70 countries, for the purpose of stroke prevention in patients with atrial fibrillation, and for the prevention of thrombosis after orthopaedic hip and knee surgery (van Ryn et al., 2013).<\/p>\n<p>Whilst dabigatran seems to be a highly effective anticoagulant with a good safety profile thus far, it is important to note that it is primarily used in patients who don\u2019t have Antiphospholipid Syndrome. International guidelines still indicate <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC8368436\/\" rel=\"noopener\" target=\"_blank\">VKAs as the choice drug<\/a> for patients with APS, especially if they have experienced a blood clotting event before, or are a high-risk patient, such as being triple positive (Pastori et al., 2021).<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#strokes\">Strokes<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#TriplePos\">Triple Positive<\/a>\n<\/div>\n<h2 id=\"FactorXa\"><strong>DOACs: Factor Xa Inhibitors<\/strong><\/h2>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4321604\/\" rel=\"noopener\" target=\"_blank\">Factor Xa inhibitors<\/a> on the other hand, reduces thrombin generation, and thus interferes with the process of fibrinogen to fibrin conversion. They also have no direct effect on platelet aggregation. It is theorised that this targeted action on factor Xa serves to limit the cascade of thrombin generation, and therefore less of the drug may be needed as compared to a DTI. Factor Xa also has minimal functions outside of coagulation, unlike thrombin, and side effects may be more contained (Cabral and Ansell, 2015).<\/p>\n<h3 id=\"apixaban\">Apixaban (Eliquis) \u2013 A Highly Selective Factor Xa Inhibitor<\/h3>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK507910\/\" rel=\"noopener\" target=\"_blank\">Apixaban (brand name: Eliquis) is a DOAC<\/a> originally approved for atrial fibrillation (Afib) patients to reduce the risk of strokes and blood clots. It was later approved to treat DVTs and PEs (pulmonary embolisms) as well. It is a highly selective factor Xa inhibitor that exerts no effect on platelet aggregation, and mainly binds to plasma protein (Agrawal et al., 22 February, 2024). <a href=\"https:\/\/medlineplus.gov\/druginfo\/meds\/a613032.html\" rel=\"noopener\" target=\"_blank\">Side effects of taking apixaban<\/a> are similar to other anticoagulant drugs, and include: bleeding, red or black, tarry stools, red, pink or brown urine, trouble breathing, dizziness, coughing up blood or material that looks like coffee grounds, and more.<\/p>\n<h3 id=\"rivaroxaban\">Rivaroxaban (Xarelto) \u2013 Another Factor Xa Inhibitor<\/h3>\n<p><a href=\"https:\/\/medlineplus.gov\/druginfo\/meds\/a611049.html\" rel=\"noopener\" target=\"_blank\">Rivaroxaban (brand name: Xarelto) is another type of DOAC<\/a> under the factor Xa class. Based on the data available to date, <a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S2387020623002802\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">rivaroxaban is less effective than VKAs in the prevention of recurrent thrombosis<\/a>, but more research needs to be done as to its efficacy (Gir\u00f3n-Ortega and Gir\u00f3n-Gonz\u00e1lez, 2023).<\/p>\n<p>A <a href=\"https:\/\/ashpublications.org\/blood\/article\/132\/13\/1365\/105711\/Rivaroxaban-vs-warfarin-in-high-risk-patients-with\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">study of 120 high risk APS patients was terminated early<\/a> due to the higher incidence of thromboembolic events for those who were on rivaroxaban, whereas none occurred in the group on warfarin (Pengo et al., 2018).<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#SectionB\">Blood Clots &amp; Bleeding<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#coagulation\">Coagulation<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#platelets\">Platelets<\/a>\n<\/div>\n<p><strong class=\"pinTxtCTA\">Pin to Your Medications and Antiphospholipid Syndrome Boards:<\/strong><\/p>\n<div class=\"pinBox\">\n<img decoding=\"async\" loading=\"lazy\" data-pin-description=\"Learn all about the medications used for the treatment and management of Antiphospholipid Syndrome and its potential medical complications.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"All the Medications Used for the Treatment and Management of Antiphospholipid Syndrome\" width=\"683\" height=\"1024\" class=\"alignnone size-large wp-image-43164 lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/all-medications-treatment-management-antiphospholipid-syndrome-683x1024.jpg?strip=all&amp;lossy=1&amp;ssl=1\">\n<\/div>\n<h2 id=\"reversal\"><strong>Current Reversal Agents Available for Anticoagulant Drugs<\/strong><\/h2>\n<p>Patients who are on anticoagulants ironically run the risk of excessive bleeding or a haemorrhage, and not all DOACs have an antidote; the antidotes that are available are also expensive. In cases of severe bleeding, patients need to undergo reversal of their anticoagulant medication via a haemostatic agent.<\/p>\n<p><a href=\"https:\/\/www.jacc.org\/doi\/abs\/10.1016\/j.jacc.2020.04.053\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">According to Tomaselli et al. (2020)<\/a> and <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6963825\/\" rel=\"noopener\" target=\"_blank\">Kustos and Fasinu (2019)<\/a>, these are the current reversal agents used for anticoagulant drugs during emergencies:<\/p>\n<ol>\n<li><strong>Vitamin K Antagonists (warfarin)<\/strong> \u2013 Intravenous or oral vitamin K1. In addition, <a href=\"https:\/\/onlinelibrary.wiley.com\/doi\/full\/10.5694\/mja12.10614\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">prothrombin complex concentrate (PCC) is preferred for immediate reversal<\/a>, as compared to fresh frozen plasma (FFP) (Tran et al., 2013). Compared to FFP, 4F-PCCs contain approximately 25 times the concentration of vitamin K-dependent factors, and thus can be given at a smaller volume with a faster infusion rate.<\/li>\n<li><strong>Vitamin K Antagonists (heparin)<\/strong> \u2013 Protamine.<\/li>\n<li><strong>Indirect Thrombin Inhibitors (LMWH)<\/strong> \u2013 Protamine.<\/li>\n<li><strong>DTI (dabigatran)<\/strong> \u2013 Idarucizumab (Praxbind). If unavailable, PCC or aPCC (activated prothrombin complex concentrate).<\/li>\n<li><strong>Factor Xa Inhibitors (apixaban &amp; rivaroxaban)<\/strong> \u2013 Andexanet Alfa. If unavailable, PCC or aPCC.<\/li>\n<li><strong>Factor Xa (betrixaban &amp; edoxaban)<\/strong> \u2013 Off-label treatment with high dose Andexanet Alfa. If unavailable, PCC or aPCC.<\/li>\n<li>In addition for the DOACs, activated charcoal may be considered for known recent ingestion in the last 2 \u2013 4 hours.<\/li>\n<\/ol>\n<p><strong><em>This is just a brief, general guideline, and many more considerations need to be taken into account on an individual basis during an emergency. Please work with your own doctors and emergency care team for the best outcome.<\/em><\/strong><\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#bleeding\">Bleeding<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#haemorrhage\">Haemorrhage<\/a>\n<\/div>\n<h3 id=\"alfa\">A Bit More About Andexanet Alfa as a Reversal Agent<\/h3>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6963825\/\" rel=\"noopener\" target=\"_blank\">Andexanet alfa<\/a> is administered via intravenous infusion with an onset time of 2 minutes. Side effects are primarily hot flashes and antibody development; they may also induce blood clotting ironically and result in strokes, DVTs, PEs, cardiac failure and more (Kustos and Fasinu, 2019; also see Escal et al., 2024). It is currently only approved for use as an antidote for apixaban and rivaroxaban, whilst its safety and efficacy is still being evaluated in relation to edoxaban and betrixaban.<\/p>\n<p><strong><a href=\"https:\/\/www.achronicvoice.com\/2024\/07\/02\/how-does-antiphospholipid-syndrome-affect-the-body-blood-major-organs\/\">Learn more about how APS affects major organs such as the lungs, brain and heart in this post<\/a>.<\/strong><\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#BloodClots\">Blood Clots<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#strokes\">Strokes<\/a>\n<\/div>\n<h3 id=\"ciraparantag\">Ciraparantag &amp; Other Non-Specific Pharmacokinetic Antidotes to DOACs<\/h3>\n<p>Ciraparantag is a reversal agent still undergoing clinical trials, but shows promise as a non-immunogenic antidote for a wide array of anticoagulants (all types of DOACs, heparins and fondaparinux) (Escal et al., 2024).<\/p>\n<p>Non-specific pharmacokinetic antidotes are sometimes used in addition to reversal agents to increase coagulation effects. <a href=\"https:\/\/onlinelibrary.wiley.com\/doi\/abs\/10.1111\/fcp.12992\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">According to Escal et al. (2024)<\/a>, these include:<\/p>\n<ul>\n<li><strong>Activated Charcoal<\/strong> \u2013 Activated charcoal has the ability to absorb various substances in the body within the gastrointestinal tract. It may help to reduce blood concentrations of DOACs and thus its bioavailability. It also remains active for a long time and is low in cost.<\/li>\n<li><strong>Haemodialysis<\/strong> \u2013 This is more for patients on DTIs (dabigatran), and especially if they have renal impairment. They are ineffective for Factor Xa inhibitors as they mainly bind to plasma proteins. It can be difficult to access during emergency situations however, as it requires trained healthcare professionals who know how to use specific equipment.<\/li>\n<li><strong>Haemostatic Agents<\/strong> \u2013 These are useful when the type of DOAC the patient is on is unknown, or when standard reversal agents are unavailable. They include naPCC (non-activated prothrombin complex concentrates), FEIBA (factor eight inhibitor bypassing activity), rFVIIa (recombinant activated factor VII) and tranexamic acid. Note that these are second-line treatments and that more research still needs to be done to determine their exact effects and safety profile.<\/li>\n<\/ul>\n<p><strong class=\"pinTxtCTA\">Pin to Your Medications and Antiphospholipid Syndrome Boards:<\/strong><\/p>\n<div class=\"pinBox\">\n<img decoding=\"async\" loading=\"lazy\" data-pin-description=\"Learn more about anticoagulants such as vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) used for the management of Antiphospholipid Syndrome, and the current approved reversal agents in cases of excessive bleeding emergency situations.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"Current Reversal Agents Available for Anticoagulants (Medications and Antiphospholipid Syndrome Series)\" width=\"200\" height=\"300\" class=\"alignnone size-medium wp-image-43267 lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/current-reversal-agents-anticoagulants-medications-and-antiphospholipid-syndrome-series-1-200x300.jpg?strip=all&amp;lossy=1&amp;ssl=1\">\n<\/div>\n<h2 id=\"PAR\"><strong>Proteases &amp; Protease-Activated Receptor (PAR) Antagonists<\/strong><\/h2>\n<p>Proteases are important regulators of cellular activity, and they communicate directly to cells via <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7845062\/\" rel=\"noopener\" target=\"_blank\">protease-activated receptors (PARs)<\/a>. There are four different PAR profiles, from PAR1 to PAR4, which are expressed widely in the body, from the brain to lungs, muscles, bones, bladder and more (Han et al., 2021). PAR1, PAR3 and PAR4 are activated by thrombin, whereas Factor Xa activates PAR2, although other proteases can also <a href=\"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/ATVBAHA.118.311655\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">contribute to activation<\/a> (Posma et al., 2019).<\/p>\n<h3>Cleavage of PARs<\/h3>\n<p>Inflammation is at the tail end of the blood coagulation cascade, as can be seen from a <a href=\"https:\/\/www.ahajournals.org\/doi\/10.1161\/ATVBAHA.118.311655\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">graphic in this paper by Posma et al. (2019)<\/a>.<\/p>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6476404\/\" rel=\"noopener\" target=\"_blank\">According to Burzynski et al. (2019)<\/a>:<\/p>\n<blockquote>\n<p>\u201cThe current principal link between coagulation and immunity is cleavage of PARs by thrombin, which produces cytokines and inflammation.\u201d<\/p>\n<\/blockquote>\n<p>This reveals a direct link between coagulation and the immune system, which is an exciting perspective. What this means is that future Antiphospholipid Syndrome treatments might shift to an immunological one, instead of merely targeting anticoagulation. Unfortunately, despite the implication of PARs in Antiphospholipid Syndrome, there are <a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S1043661817312550?via%3Dihub\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">no ongoing trials for APS patients<\/a> (Signorelli et al., 2018). Let\u2019s keep our fingers crossed! (<strong><a href=\"https:\/\/www.achronicvoice.com\/2024\/06\/02\/latest-research-on-antiphospholipid-syndrome\/\">Read this post for the latest research on APS<\/a>.<\/strong>)<\/p>\n<h3 id=\"vorapaxar\">Vorapaxar \u2013 An FDA-Approved PAR Antagonist<\/h3>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7845062\/\" rel=\"noopener\" target=\"_blank\">Vorapaxar is a first-in-class PAR1 antagonist<\/a> approved for use by the FDA, for patients with <a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S1043661817312550\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">coronary artery disease<\/a>. Unfortunately, it is contraindicated for patients who have had thrombotic or bleeding events in the past. Like all antiplatelet agents, vorapaxar increases the risk of bleeding, which can be fatal. It also has a long half-life and no antidote (Han et al., 2021; Signorelli et al., 2018).<\/p>\n<p>Another PAR-1 antagonist is atopaxar, but <a href=\"https:\/\/www.tandfonline.com\/doi\/abs\/10.1517\/13543784.2013.832198\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">research has been discontinued<\/a> as clinical trials in phase II demonstrated a high risk for bleeding with the drug (Zhao et al., 2013).<\/p>\n<h2 id=\"NSAIDs\"><strong>NSAIDs &amp; Antiphospholipid Syndrome<\/strong><\/h2>\n<p><a href=\"https:\/\/www.health.harvard.edu\/diseases-and-conditions\/bad-mix-blood-thinners-and-nsaids\" rel=\"noopener\" target=\"_blank\">NSAIDs<\/a> (Non-Steroidal Anti-Inflammatory Drugs) are a class of anti-inflammatories that people often take for generic pain relief. You\u2019re probably familiar with these over-the-counter drugs that go by the names of: Ibuprofen, Naproxen and Aspirin. Brand names include Neurofen, Advil, Motrin, Aleve, Alka-Seltzer, Pepto-Bismol, and more.<\/p>\n<p>To be honest, NSAIDS would probably work better for my Lupus and Sj\u00f6gren\u2019s pains because of their anti-inflammatory properties, but I can\u2019t take them due to interactions with warfarin. As I\u2019m also allergic to paracetamol (Panadol), I can only rely on opioid classes of painkillers for pain relief.<\/p>\n<p>NSAIDs interfere with blood clotting by inhibiting platelet function. <a href=\"https:\/\/my.clevelandclinic.org\/health\/body\/22879-platelets\" rel=\"noopener\" target=\"_blank\">Platelets<\/a> (also known as thrombocytes) are essential components in our blood that help with clotting. Hence, patients who are on blood thinning medications have a higher risk of bleeding with NSAIDs.<\/p>\n<p>There is also an increased <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5478398\/\" rel=\"noopener\" target=\"_blank\">risk of gastrointestinal bleeding and peptic ulcers with NSAIDs<\/a> due to the mechanisms of the medication (Drini, 2017), which is also the biggest concern my rheumatologist has with them. I only use NSAIDs when absolutely necessary, such as during a high fever, and inform my healthcare team when I do so. I also take extra measures to protect my stomach such as eating proper meals, and check my own INR regularly.<\/p>\n<div class=\"relatedList\">\nQuick Link Guide: <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#INR\">INR<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#SectionL\">Lupus &amp; Lupus Anticoagulant<\/a> | <a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/#platelets\">Platelets<\/a>\n<\/div>\n<ul class=\"relatedList\">\n<u>Read Related Posts:<\/u><\/p>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2019\/09\/22\/painkillers-quality-life\/\">Why Painkillers are One of My Biggest Allies for a Decent Quality of Life<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2021\/03\/18\/oral-spray-vitamins\/\">Oral Spray Vitamins: A Quick &amp; Easy Way to Get Your Nutrients with Chronic Illness<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2016\/04\/23\/high-dose-steroids\/\">What\u2019s it Like to be on a High Dose of Steroids? (And the First Question You Will Definitely Ask)<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2020\/02\/13\/drink-pure-wine-review\/\">Drink Pure Wine Review (A Product That Excites Me as a Person with Chronic Illness)<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2021\/07\/14\/body-gone-rogue-invisible-illness\/\">12 Visible Evidence of a Body Gone Rogue (Is Invisible Illness Truly Invisible?)<\/a><\/li>\n<\/ul>\n<p><strong class=\"pinTxtCTA\">Pin to Your Medications and Antiphospholipid Syndrome Boards:<\/strong><\/p>\n<div class=\"pinBox\">\n<img decoding=\"async\" loading=\"lazy\" data-pin-description=\"Learn more about medications and Antiphospholipid Syndrome - from essential coagulants to potential interactions and other useful information.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"Medications that Antiphospholipid Syndrome Patients Need to be Aware of\" width=\"683\" height=\"1024\" class=\"alignnone size-large wp-image-43170 lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/medications-antiphospholipid-syndrome-patients-aware-683x1024.jpg?strip=all&amp;lossy=1&amp;ssl=1\">\n<\/div>\n<h2><strong>Conclusion to Medications and Antiphospholipid Syndrome<\/strong><\/h2>\n<p>In this post, we have covered medications and Antiphospholipid Syndrome, as well as some of the important drugs that can interact with warfarin, and new medications that are undergoing clinical trials.<\/p>\n<p>I hope that this post on medications and Antiphospholipid Syndrome has been insightful and useful to you whether as an APS patient, or someone who is caring for one. Should you have any questions, experiences to share, or corrections (I am not a doctor, after all!), feel free to leave a comment below. Don\u2019t forget to check out the rest of the posts in the Antiphospholipid Syndrome series listed below as well. Wishing you all the best that life can still bring!<\/p>\n<p><strong>P.s. If you\u2019d like to support the work I do, you can keep me fueled with coffee using the button below. You can also <a href=\"https:\/\/eepurl.com\/bVyAbn\" target=\"_blank\" class=\"contentLink\" rel=\"noopener noreferrer\">sign up for our mailing list<\/a> so you don\u2019t miss out on our latest posts. You will receive an e-book full of uplifting messages, quotes and illustrations, as a token of appreciation!<\/strong><\/p>\n<p><a class=\"pinkBtn broken_link\" href=\"https:\/\/buymeacoffee.com\/achronicvoice\" target=\"_blank\" rel=\"noopener\">Feed Sheryl Coffee Here<\/a><\/p>\n<ul class=\"relatedList\">\n<u>Read Related Posts in the Antiphospholipid Syndrome Series:<\/u><\/p>\n<li><a href=\"https:\/\/www.achronicvoice.com\/antiphospholipid-syndrome-diagnosis-a-to-z-guide\/\">Antiphospholipid Syndrome Diagnosis: The A to Z Guide as a Patient<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2024\/06\/02\/latest-research-on-antiphospholipid-syndrome\/\">Latest Research on Antiphospholipid Syndrome<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2024\/06\/08\/womens-health-in-antiphospholipid-syndrome\/\">Pregnancy, Miscarriage &amp; Women\u2019s Health in Antiphospholipid Syndrome<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2018\/05\/27\/living-with-antiphospholipid-syndrome-personal-experiences\/\">The Annoying Thing About Living with Antiphospholipid Syndrome (My Personal Experiences)<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2016\/04\/08\/thromboembolism-antiphospholipid-syndrome\/\">An Experience from Hell: Thromboembolism From Antiphospholipid Syndrome<\/a><\/li>\n<li><a href=\"https:\/\/www.achronicvoice.com\/2019\/08\/08\/sgh-hospital-emergency\/\">What it Feels Like to be Refused Treatment by a Hospital\u2019s A&amp;E<\/a><\/li>\n<\/ul>\n<p><strong class=\"pinTxtCTA\">Pin to Your Medications and Antiphospholipid Syndrome Boards:<\/strong><\/p>\n<div class=\"pinBox\">\n<img decoding=\"async\" loading=\"lazy\" data-pin-description=\"Get the lowdown on all medications used for the management and treatment of Antiphospholipid Syndrome, as well as potential interactions and other must-knows.\" src=\"data:image\/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==\" alt=\"The Lowdown on Medications and Antiphospholipid Syndrome (Warfarin, Enoxaparin, DOACs, NSAIDs and More)\" width=\"200\" height=\"300\" class=\"alignnone size-medium wp-image-43268 pinBorder lazyload\" data-src=\"https:\/\/e4edn27usvk.exactdn.com\/wp-content\/uploads\/2024\/06\/lowdown-medications-and-antiphospholipid-syndrome-warfarin-enoxaparin-doacs-nsaids-1-1-200x300.jpg?strip=all&amp;lossy=1&amp;ssl=1\">\n<\/div>\n<ol class=\"insightList references mb10\">\n<h3 style=\"margin:0;font-size:13px;text-decoration:underline\">References:<\/h3>\n<li>Agrawal, A., Kerndt, C. C., &amp; Manna, B. (22 February, 2024). Apixaban. In <em>StatPearls<\/em>. StatPearls Publishing. Retrieved from: <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK507910\/\" rel=\"noopener\" target=\"_blank\">http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK507910\/<\/a><\/li>\n<li>Albrecht, D., Ellis, D., Canafax, D. M., Combs, D., Druzgala, P., Milner, P. G., &amp; Midei, M. G. (2017). Pharmacokinetics and pharmacodynamics of tecarfarin, a novel vitamin K antagonist oral anticoagulant. <em>Thrombosis and Haemostasis, 117<\/em>(04), 706-717. <a href=\"https:\/\/doi.org\/10.1160\/TH16-08-0623\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1160\/TH16-08-0623<\/a><\/li>\n<li>Barmore, W., Bajwa, T., &amp; Burns, B. (24 February, 2023). Biochemistry, Clotting Factors. In <em>StatPearls<\/em>. StatPearls Publishing. Retrieved from: <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK507850\/\" rel=\"noopener\" target=\"_blank\">http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK507850\/<\/a><\/li>\n<li>Bejjani, A., Khairani, C. D., Assi, A., Piazza, G., Sadeghipour, P., Talasaz, A. H., Fanikos, J., Connors, J. M., Siegal, D. M., Barnes, G. D., Martin, K. A., Angiolillo, D. J., Kleindorfer, D., Monreal, M., Jimenez, D., Middeldorp, S., Elkind, M. S. V., Ruff, C. T., Goldhaber, S. Z., \u2026 Bikdeli, B. (2024). When Direct Oral Anticoagulants Should Not Be Standard Treatment. <em>Journal of the American College of Cardiology, 83<\/em>(3), 444\u2013465. <a href=\"https:\/\/doi.org\/10.1016\/j.jacc.2023.10.038\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1016\/j.jacc.2023.10.038<\/a><\/li>\n<li>Burzynski, L. C., Humphry, M., Pyrillou, K., Wiggins, K. A., Chan, J. N. E., Figg, N., Kitt, L. L., Summers, C., Tatham, K. C., Martin, P. B., Bennett, M. R., &amp; Clarke, M. C. H. (2019). The Coagulation and Immune Systems Are Directly Linked through the Activation of Interleukin-1\u03b1 by Thrombin. <em>Immunity, 50<\/em>(4), 1033-1042.e6. <a href=\"https:\/\/doi.org\/10.1016\/j.immuni.2019.03.003\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1016\/j.immuni.2019.03.003<\/a><\/li>\n<li>Cabral, K. P., &amp; Ansell, J. E. (2015). The role of factor Xa inhibitors in venous thromboembolism treatment. <em>Vascular Health and Risk Management, 11<\/em>, 117\u2013123. <a href=\"https:\/\/doi.org\/10.2147\/VHRM.S39726\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.2147\/VHRM.S39726<\/a><\/li>\n<li>Cadrenal Therapeutics, Inc. (3 June, 2024). <em>Cadrenal Therapeutics Highlights Presentation Of New Trial Data at Ishlt Conference Demonstrating The Importance Of Anticoagulation Quality In LVAD Patients<\/em>. Cadrenal Therapeutics, Inc. Retrieved from: <a href=\"https:\/\/www.cadrenal.com\/investors\/press-releases\/detail\/cadrenal-therapeutics-provides-third-quarter-2023-corporate-update\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/www.cadrenal.com\/investors\/press-releases\/detail\/cadrenal-therapeutics-provides-third-quarter-2023-corporate-update<\/a><\/li>\n<li>Cadrenal Therapeutics, Inc. (9 November, 2023). <em>Cadrenal Therapeutics Provides Third Quarter 2023 Corporate Update<\/em>. U.S. Securities And Exchange Commission. Retrieved from: <a href=\"https:\/\/www.sec.gov\/Archives\/edgar\/data\/1937993\/000121390023084969\/ea187953ex99-1_cadrenal.htm\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/www.sec.gov\/Archives\/edgar\/data\/1937993\/000121390023084969\/ea187953ex99-1_cadrenal.htm<\/a><\/li>\n<li>Cadrenal Therapeutics, Inc. (n.d.). <em>Tecarfarin. A late-stage novel therapy with orphan drug and Fast Track designations<\/em>. Cadrenal Therapeutics, Inc. Retrieved from: <a href=\"https:\/\/www.cadrenal.com\/tecarfarin\/\" rel=\"noopener\" target=\"_blank\">https:\/\/www.cadrenal.com\/tecarfarin\/<\/a><\/li>\n<li>Cleveland Clinic. (28 April, 2022). <em>Platelets<\/em>. Cleveland Clinic. Retrieved from: <a href=\"https:\/\/my.clevelandclinic.org\/health\/body\/22879-platelets\" rel=\"noopener\" target=\"_blank\">https:\/\/my.clevelandclinic.org\/health\/body\/22879-platelets<\/a><\/li>\n<li>Cook, B. W. (2010). Anticoagulation Management. <em>Seminars in Interventional Radiology, 27<\/em>(4), 360\u2013367. <a href=\"https:\/\/doi.org\/10.1055\/s-0030-1267849\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1055\/s-0030-1267849<\/a><\/li>\n<li>Crader, M. F., Johns, T., &amp; Arnold, J. K. (1 May, 2023). Warfarin Drug Interactions. In <em>StatPearls<\/em>. StatPearls Publishing. Retrieved from: <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK441964\/\" rel=\"noopener\" target=\"_blank\">http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK441964\/<\/a><\/li>\n<li>Department of Health, Government of Western Australia. (n.d.). <em>Warfarin<\/em>. HealthyWA. Retrieved from: <a href=\"https:\/\/www.healthywa.wa.gov.au\/Articles\/U_Z\/Warfarin\" rel=\"noopener\" target=\"_blank\">https:\/\/www.healthywa.gov.au\/Articles\/A-Z\/Warfarin<\/a><\/li>\n<li>Drini, M. (2017). Peptic ulcer disease and non-steroidal anti-inflammatory drugs. <em>Australian Prescriber, 40<\/em>(3), 91\u201393. <a href=\"https:\/\/doi.org\/10.18773\/austprescr.2017.037\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.18773\/austprescr.2017.037<\/a><\/li>\n<li>Drugs .com. (n.d.). <em>Enoxaparin (Ingredient)<\/em>. Drugs .com. Retrieved from: <a href=\"https:\/\/www.drugs.com\/ingredient\/enoxaparin.html\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/www.drugs.com\/ingredient\/enoxaparin.html<\/a><\/li>\n<li>Ellis, D. J., Usman, M. H., Milner, P. G., Canafax, D. M., &amp; Ezekowitz, M. D. (2009). The First Evaluation of a Novel Vitamin K Antagonist, Tecarfarin (ATI-5923), in Patients With Atrial Fibrillation. <em>Circulation, 120<\/em>(12), 1029\u20131035. <a href=\"https:\/\/doi.org\/10.1161\/CIRCULATIONAHA.109.856120\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1161\/CIRCULATIONAHA.109.856120<\/a><\/li>\n<li>Eriksson, B. I., Quinlan, D. J., &amp; Eikelboom, J. W. (2011). Novel Oral Factor Xa and Thrombin Inhibitors in the Management of Thromboembolism. <em>Annual Review of Medicine, 62<\/em>(Volume 62, 2011), 41\u201357. <a href=\"https:\/\/doi.org\/10.1146\/annurev-med-062209-095159\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1146\/annurev-med-062209-095159<\/a><\/li>\n<li>Escal, J., Lanoisel\u00e9e, J., Poenou, G., Zufferey, P., Laporte, S., Mismetti, P., &amp; Delavenne, X. (2024). Latest advances in the reversal strategies for direct oral anticoagulants. <em>Fundamental &amp; Clinical Pharmacology<\/em>. <a href=\"https:\/\/doi.org\/10.1111\/fcp.12992\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1111\/fcp.12992<\/a><\/li>\n<li>Girolami, A., Ferrari, S., Cosi, E., Santarossa, C., &amp; Randi, M. L. (2018). Vitamin K-Dependent Coagulation Factors That May be Responsible for Both Bleeding and Thrombosis (FII, FVII, and FIX). <em>Clinical and Applied Thrombosis\/Hemostasis, 24<\/em>(9 Suppl), 42S-47S. <a href=\"https:\/\/doi.org\/10.1177\/1076029618811109\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1177\/1076029618811109<\/a><\/li>\n<li>Gir\u00f3n-Ortega, J. A., &amp; Gir\u00f3n-Gonz\u00e1lez, J. A. (2023). Direct-acting oral anticoagulants in antiphospholipid syndrome: A systematic review. <em>Medicina Cl\u00ednica (English Edition), 161<\/em>(2), 65\u201377. <a href=\"https:\/\/doi.org\/10.1016\/j.medcle.2023.03.017\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1016\/j.medcle.2023.03.017<\/a><\/li>\n<li>Gruel, Y., De Maistre, E., Pouplard, C., Mullier, F., Susen, S., Roullet, S., Blais, N., Le Gal, G., Vincentelli, A., Lasne, D., Lecompte, T., Albaladejo, P., Godier, A., Albaladejo, P., Belisle, S., Blais, N., Bonhomme, F., Borel-Derlon, A., Borg, J. Y., \u2026 Zufferey, P. (2020). Diagnosis and management of heparin-induced thrombocytopenia. <em>Anaesthesia Critical Care &amp; Pain Medicine, 39<\/em>(2), 291\u2013310. <a href=\"https:\/\/doi.org\/10.1016\/j.accpm.2020.03.012\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1016\/j.accpm.2020.03.012<\/a><\/li>\n<li>Halder, M., Petsophonsakul, P., Akbulut, A. C., Pavlic, A., Bohan, F., Anderson, E., Maresz, K., Kramann, R., &amp; Schurgers, L. (2019). Vitamin K: Double Bonds beyond Coagulation Insights into Differences between Vitamin K1 and K2 in Health and Disease. <em>International Journal of Molecular Sciences, 20<\/em>(4), Article 4. <a href=\"https:\/\/doi.org\/10.3390\/ijms20040896\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.3390\/ijms20040896<\/a><\/li>\n<li>Han, X., Nieman, M. T., &amp; Kerlin, B. A. (2020). Protease\u2010activated receptors: An illustrated review. <em>Research and Practice in Thrombosis and Haemostasis, 5<\/em>(1), 17\u201326. <a href=\"https:\/\/doi.org\/10.1002\/rth2.12454\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1002\/rth2.12454<\/a><\/li>\n<li>Harvard Medical School. (16 December, 2019). <em>Bad mix: Blood thinners and NSAIDs<\/em>. Harvard Health Publishing. Retrieved from: <a href=\"https:\/\/www.health.harvard.edu\/diseases-and-conditions\/bad-mix-blood-thinners-and-nsaids\" rel=\"noopener\" target=\"_blank\">https:\/\/www.health.harvard.edu\/diseases-and-conditions\/bad-mix-blood-thinners-and-nsaids<\/a><\/li>\n<li>Holbrook, A. M., Pereira, J. A., Labiris, R., McDonald, H., Douketis, J. D., Crowther, M., &amp; Wells, P. S. (2005). Systematic Overview of Warfarin and Its Drug and Food Interactions. <em>Archives of Internal Medicine, 165<\/em>(10), 1095\u20131106. <a href=\"https:\/\/doi.org\/10.1001\/archinte.165.10.1095\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1001\/archinte.165.10.1095<\/a><\/li>\n<li>Jupalli, A., &amp; Iqbal, A. M. (28 August, 2023). Enoxaparin. In <em>StatPearls<\/em>. StatPearls Publishing. Retrieved from: <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK539865\/\" rel=\"noopener\" target=\"_blank\">http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK539865\/<\/a><\/li>\n<li>Kasperkiewicz, K., Ponczek, M. B., Owczarek, J., Guga, P., &amp; Budzisz, E. (2020). Antagonists of Vitamin K\u2014Popular Coumarin Drugs and New Synthetic and Natural Coumarin Derivatives. <em>Molecules, 25<\/em>(6), 1465. <a href=\"https:\/\/doi.org\/10.3390\/molecules25061465\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.3390\/molecules25061465<\/a><\/li>\n<li>Krishnaswamy, A., Lincoff, A. M., &amp; Cannon, C. P. (2010). The Use and Limitations of Unfractionated Heparin. <em>Critical Pathways in Cardiology, 9<\/em>(1), 35. <a href=\"https:\/\/doi.org\/10.1097\/HPC.0b013e3181d29713\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1097\/HPC.0b013e3181d29713<\/a><\/li>\n<li>Kustos, S. A., &amp; Fasinu, P. S. (2019). Direct-Acting Oral Anticoagulants and Their Reversal Agents-An Update. <em>Medicines (Basel, Switzerland), 6<\/em>(4), 103. <a href=\"https:\/\/doi.org\/10.3390\/medicines6040103\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.3390\/medicines6040103<\/a><\/li>\n<li>Lawrence, P. F. (2011). Chapter 78\u2014Pharmacologic Adjuncts to Endovascular Procedures. In W. S. Moore &amp; S. S. Ahn (Eds.), <em>Endovascular Surgery (Fourth Edition)<\/em> (pp. 807\u2013813). W.B. Saunders. <a href=\"https:\/\/doi.org\/10.1016\/B978-1-4160-6208-0.10078-3\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1016\/B978-1-4160-6208-0.10078-3<\/a><\/li>\n<li>Lee, C. J., &amp; Ansell, J. E. (2011). Direct thrombin inhibitors. <em>British Journal of Clinical Pharmacology, 72<\/em>(4), 581\u2013592. <a href=\"https:\/\/doi.org\/10.1111\/j.1365-2125.2011.03916.x\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1111\/j.1365-2125.2011.03916.x<\/a><\/li>\n<li>Li, Y., Liu, L., Li, S., Sun, H., Zhang, Y., Duan, Z., &amp; Wang, D. (2022). Impaired bone healing by enoxaparin via inhibiting the differentiation of bone marrow mesenchymal stem cells towards osteoblasts. <em>Journal of Bone and Mineral Metabolism, 40<\/em>(1), 9\u201319. <a href=\"https:\/\/doi.org\/10.1007\/s00774-021-01268-5\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1007\/s00774-021-01268-5<\/a><\/li>\n<li>Mayo Clinic. (1 February, 2024). <em>Enoxaparin (Intravenous Route, Subcutaneous Route, Injection Route)<\/em>. Mayo Clinic. Retrieved from: <a href=\"https:\/\/www.mayoclinic.org\/drugs-supplements\/enoxaparin-intravenous-route-subcutaneous-route-injection-route\/side-effects\/drg-20063670?p=1\" rel=\"noopener\" target=\"_blank\">https:\/\/www.mayoclinic.org\/drugs-supplements\/enoxaparin-intravenous-route-subcutaneous-route-injection-route\/side-effects\/drg-20063670?p=1<\/a><\/li>\n<li>MedlinePlus. (15 April, 2023). <em>Rivaroxaban<\/em>. Bethesda (MD): National Library of Medicine (US). Retrieved from: <a href=\"https:\/\/medlineplus.gov\/druginfo\/meds\/a611049.html\" rel=\"noopener\" target=\"_blank\">https:\/\/medlineplus.gov\/druginfo\/meds\/a611049.html<\/a><\/li>\n<li>MedlinePlus. (15 November, 2023). <em>Apixaban<\/em>. Bethesda (MD): National Library of Medicine (US). Retrieved from: <a href=\"https:\/\/medlineplus.gov\/druginfo\/meds\/a613032.html\" rel=\"noopener\" target=\"_blank\">https:\/\/medlineplus.gov\/druginfo\/meds\/a613032.html<\/a><\/li>\n<li>Nasiri, A., AlQahtani, A., Rayes, N. H., AlQahtani, R., Alkharras, R., &amp; Alghethber, H. (2022). Direct oral anticoagulant: Review article. <em>Journal of Family Medicine and Primary Care, 11<\/em>(8), 4180\u20134183. <a href=\"https:\/\/doi.org\/10.4103\/jfmpc.jfmpc_2253_21\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.4103\/jfmpc.jfmpc_2253_21<\/a><\/li>\n<li>Office of Dietary Supplements. (29 March, 2021). <em>Vitamin K Fact Sheet for Health Professionals<\/em>. National Institutes of Health. Retrieved from: <a href=\"https:\/\/ods.od.nih.gov\/factsheets\/VitaminK-HealthProfessional\/\" rel=\"noopener\" target=\"_blank\">https:\/\/ods.od.nih.gov\/factsheets\/VitaminK-HealthProfessional\/<\/a><\/li>\n<li>Pastori, D., Menichelli, D., Cammisotto, V., &amp; Pignatelli, P. (2021). Use of Direct Oral Anticoagulants in Patients With Antiphospholipid Syndrome: A Systematic Review and Comparison of the International Guidelines. <em>Frontiers in Cardiovascular Medicine, 8<\/em>. <a href=\"https:\/\/doi.org\/10.3389\/fcvm.2021.715878\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.3389\/fcvm.2021.715878<\/a><\/li>\n<li>Pengo, V., Denas, G., Zoppellaro, G., Jose, S. P., Hoxha, A., Ruffatti, A., Andreoli, L., Tincani, A., Cenci, C., Prisco, D., Fierro, T., Gresele, P., Cafolla, A., De Micheli, V., Ghirarduzzi, A., Tosetto, A., Falanga, A., Martinelli, I., Testa, S., \u2026 Banzato, A. (2018). Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. <em>Blood, 132<\/em>(13), 1365\u20131371. <a href=\"https:\/\/doi.org\/10.1182\/blood-2018-04-848333\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1182\/blood-2018-04-848333<\/a><\/li>\n<li>Patel, S., Singh, R., Preuss, C. V., &amp; Patel, N. (24 March, 2023). Warfarin. In <em>StatPearls<\/em>. StatPearls Publishing. Retrieved from: <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK470313\/\" rel=\"noopener\" target=\"_blank\">http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK470313\/<\/a><\/li>\n<li>Posma, J. J., Grover, S. P., Hisada, Y., Owens, A. P., Antoniak, S., Spronk, H. M., &amp; Mackman, N. (2019). Roles of Coagulation Proteases and PARs (Protease-Activated Receptors) in Mouse Models of Inflammatory Diseases. <em>Arteriosclerosis, Thrombosis, and Vascular Biology, 39<\/em>(1), 13\u201324. <a href=\"https:\/\/doi.org\/10.1161\/ATVBAHA.118.311655\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1161\/ATVBAHA.118.311655<\/a><\/li>\n<li>Ruff, C. T. (17 May, 2022). <em>Direct Oral Anticoagulants (DOACs) vs. Warfarin: Key Differences<\/em>. North American Thrombosis Forum [NATF]. Retrieved from: <a href=\"https:\/\/thrombosis.org\/2020\/11\/doacs-vs-warfarin\/\" rel=\"noopener\" target=\"_blank\">https:\/\/thrombosis.org\/2020\/11\/doacs-vs-warfarin\/<\/a><\/li>\n<li>Schein, J. R., White, C. M., Nelson, W. W., Kluger, J., Mearns, E. S., &amp; Coleman, C. I. (2016). Vitamin K antagonist use: Evidence of the difficulty of achieving and maintaining target INR range and subsequent consequences. <em>Thrombosis Journal, 14<\/em>(1), 14. <a href=\"https:\/\/doi.org\/10.1186\/s12959-016-0088-y\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1186\/s12959-016-0088-y<\/a><\/li>\n<li>Shah, B. B., Shankar, A., Kumar, V., Kumar, S., Malik, U. A., Majeed, A., \u2026 &amp; Ahmed, S. (2023). Direct oral anticoagulants vs. vitamin K antagonists in patients with antiphospholipid syndrome: a systematic review and meta-analysis. <em>Annals of Medicine and Surgery, 85<\/em>(7), 3574-3582. <a href=\"https:\/\/doi.org\/10.1097\/MS9.0000000000000903\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1097\/MS9.0000000000000903<\/a><\/li>\n<li>Signorelli, F., Balbi, G. G. M., Domingues, V., &amp; Levy, R. A. (2018). New and upcoming treatments in antiphospholipid syndrome: A comprehensive review. <em>Pharmacological Research, 133<\/em>, 108\u2013120. <a href=\"https:\/\/doi.org\/10.1016\/j.phrs.2018.04.012\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1016\/j.phrs.2018.04.012<\/a><\/li>\n<li>Takahashi, H., &amp; Echizen, H. (2003). Pharmacogenetics of CYP2C9 and interindividual variability in anticoagulant response to warfarin. <em>The Pharmacogenomics Journal, 3<\/em>(4), 202\u2013214. <a href=\"https:\/\/doi.org\/10.1038\/sj.tpj.6500182\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1038\/sj.tpj.6500182<\/a><\/li>\n<li>Tay, K. H., Shantsila, E., &amp; Lip, G. Y. H. (2013). The Coagulation Pathway and Approaches to Anticoagulation. In G. Y. Lip &amp; E. Shantsila (Eds.), <em>Handbook of Oral Anticoagulation<\/em> (pp. 1\u20135). Springer Healthcare Ltd. <a href=\"https:\/\/doi.org\/10.1007\/978-1-908517-96-8_1\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1007\/978-1-908517-96-8_1<\/a><\/li>\n<li>Thijssen, H. H. W. (1995). Warfarin-based rodenticides: Mode of action and mechanism of resistance. <em>Pesticide Science, 43<\/em>(1), 73\u201378. <a href=\"https:\/\/doi.org\/10.1002\/ps.2780430112\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1002\/ps.2780430112<\/a><\/li>\n<li>Tomaselli, G. F., Mahaffey, K. W., Cuker, A., Dobesh, P. P., Doherty, J. U., Eikelboom, J. W., Florido, R., Gluckman, T. J., Hucker, W. J., Mehran, R., Mess,  \u00e9 S. R., Perino, A. C., Rodriguez, F., Sarode, R., Siegal, D. M., &amp; Wiggins, B. S. (2020). 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. <em>Journal of the American College of Cardiology, 76<\/em>(5), 594\u2013622. <a href=\"https:\/\/doi.org\/10.1016\/j.jacc.2020.04.053\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1016\/j.jacc.2020.04.053<\/a><\/li>\n<li>Tran, H., Joseph, J., Young, L., McRae, S., Curnow, J., Nandurkar, H., Wood, P., &amp; McLintock, C. (2014). New oral anticoagulants: A practical guide on prescription, laboratory testing and peri-procedural\/bleeding management. <em>Internal Medicine Journal, 44<\/em>(6), 525\u2013536. <a href=\"https:\/\/doi.org\/10.1111\/imj.12448\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1111\/imj.12448<\/a><\/li>\n<li>Tran, H. A., Chunilal, S. D., Harper, P. L., Tran, H., Wood, E. M., &amp; Gallus, A. S. (2013). An update of consensus guidelines for warfarin reversal. <em>Medical Journal of Australia, 198<\/em>(4), 198\u2013199. <a href=\"https:\/\/doi.org\/10.5694\/mja12.10614\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.5694\/mja12.10614<\/a><\/li>\n<li>U.S. Food &amp; Drug Administration. (2 June, 2018). <em>Generic Enoxaparin Questions and Answers<\/em>. FDA. Retrieved from: <a href=\"https:\/\/www.fda.gov\/drugs\/postmarket-drug-safety-information-patients-and-providers\/generic-enoxaparin-questions-and-answers\" rel=\"noopener\" target=\"_blank\">https:\/\/www.fda.gov\/drugs\/postmarket-drug-safety-information-patients-and-providers\/generic-enoxaparin-questions-and-answers<\/a><\/li>\n<li>van Ryn, J., Goss, A., Hauel, N., Wienen, W., Priepke, H., Nar, H., &amp; Clemens, A. (2013). The Discovery of Dabigatran Etexilate. <em>Frontiers in Pharmacology, 4<\/em>, 12. <a href=\"https:\/\/doi.org\/10.3389\/fphar.2013.00012\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.3389\/fphar.2013.00012<\/a><\/li>\n<li>Vardanyan, R. S., &amp; Hruby, V. J. (2006). 24\u2014Anticoagulants, Antiaggregants, Thrombolytics, and Hemostatics. In R. S. Vardanyan &amp; V. J. Hruby (Eds.), <em>Synthesis of Essential Drugs<\/em> (pp. 323\u2013335). Elsevier. <a href=\"https:\/\/doi.org\/10.1016\/B978-044452166-8\/50024-8\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1016\/B978-044452166-8\/50024-8<\/a><\/li>\n<li>Wadelius, M., S\u00f6rlin, K., Wallerman, O., Karlsson, J., Yue, Q.-Y., Magnusson, P. K. E., Wadelius, C., &amp; Melhus, H. (2004). Warfarin sensitivity related to CYP2C9, CYP3A5, ABCB1 (MDR1) and other factors. <em>The Pharmacogenomics Journal, 4<\/em>(1), 40\u201348. <a href=\"https:\/\/doi.org\/10.1038\/sj.tpj.6500220\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1038\/sj.tpj.6500220<\/a><\/li>\n<li>Zhao, H.-P., Jiang, H.-M., &amp; Xiang, B.-R. (2013). Discontinued drugs in 2012: Cardiovascular drugs. <em>Expert Opinion on Investigational Drugs, 22<\/em>(11), 1437\u20131451. <a href=\"https:\/\/doi.org\/10.1517\/13543784.2013.832198\" rel=\"noopener\" target=\"_blank\" class=\"broken_link\">https:\/\/doi.org\/10.1517\/13543784.2013.832198<\/a><\/li>\n<li>Zhou, Q., Wang, Z., Wang, H., Chen, Z., Li, X., Dai, X., Zhang, Y., Yu, X., Zhou, R., &amp; Hu, W. (2023). Safety and Tolerability of Tecarfarin (ATI-5923) in Healthy Chinese Volunteers: Multiple Oral Dose-Escalation Phase I Trial. <em>American Journal of Cardiovascular Drugs, 23<\/em>(1), 101\u2013112. <a href=\"https:\/\/doi.org\/10.1007\/s40256-022-00562-5\" rel=\"noopener\" target=\"_blank\">https:\/\/doi.org\/10.1007\/s40256-022-00562-5<\/a><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>This article is part of the Antiphospholipid Syndrome (APS) resource library that I\u2019m building up&#8230;<\/p>\n","protected":false},"author":1,"featured_media":270,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[12],"tags":[],"class_list":["post-475","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-chronic-voices"],"_links":{"self":[{"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/posts\/475","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/comments?post=475"}],"version-history":[{"count":1,"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/posts\/475\/revisions"}],"predecessor-version":[{"id":476,"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/posts\/475\/revisions\/476"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/media\/270"}],"wp:attachment":[{"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/media?parent=475"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/categories?post=475"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/guidestonefinancialgroup.com\/index.php\/wp-json\/wp\/v2\/tags?post=475"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}