To the Editor: In their Clinical Review of antiphospholipid antibody syndrome (APS) management, Dr Lim and colleagues1 examine evidence for treatment of 2 distinct groups of patients: those with antiphospholipid antibodies and those with definite APS. Classification criteria for definite APS, including laboratory criteria, have been recently updated.2 The new criteria reinforce the importance of persistent positivity and require positive laboratory test results at least 12 weeks apart. Data from the literature derived from patients with a single positive antiphospholipid antibody test do not apply to patients with definite APS.
Although it has been demonstrated that high-intensity warfarin is not more effective than moderate-intensity warfarin for venous thromboembolism in patients with APS,3 - 4 it has not been demonstrated that aspirin is equivalent to warfarin adjusted to a target international normalized ratio (INR) of 2.0 to 3.0 in patients with definite APS and prior stroke. Thus, the fact that aspirin and moderate-intensity warfarin are equally effective in patients with stroke with a single antiphospholipid antibody test does not mean that aspirin should be standard therapy in patients with definite APS and stroke.
Moreover, the updated criteria advise classifying patients into different categories according to antibody profile. The risk of venous thrombotic events is higher for patients with lupus anticoagulant than for patients with other antibody profiles, such as anticardiolipin antibodies in patients with systemic lupus erythematosus5 or anti-β2-glycoprotein I antibodies in patients with a first episode of deep vein thrombosis without an underlying systemic disease.6 Furthermore, positivity on multiple antiphospholipid test results may also increase thrombotic risk.2 Thus, antibody profile may modulate the risk of primary or recurrent events associated with antiphospholipid antibodies.
Lim et al note that although retrospective cohort studies7 - 8 suggested that high-intensity warfarin was associated with a better outcome in treating venous thromboembolism, this was not confirmed in later randomized controlled trials in which patients with high recurrence risk were excluded.3 - 4 However, the earlier studies suggest that at least a subgroup of patients with definite APS who experienced recurrent events despite moderate-intensity INR may require high-intensity warfarin.
Finally, Lim et al discuss treatment of asymptomatic patients who have antiphospholipid antibodies, citing a consensus opinion. We have performed a decision analysis suggesting that prophylactic low-dose aspirin could be effective in patients with systemic lupus erythematosus and antiphospholipid antibodies.9
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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