• Josep Ordi-Ros, Luis Sáez-Comet, Mercedes Pérez-Conesa, Xavier Vidal, Antoni Riera-Mestre, Antoni Castro-Salomó, Jordi Cuquet-Pedragosa, Vera Ortiz-Santamaria, Montserrat Mauri-Plana, Cristina Solé, and Josefina Cortés-Hernández.
• Vall d'Hebrón Research Institute, Barcelona, Spain (J.O., X.V., C.S., J.C.).
• Ann. Intern. Med. 2019 Nov 19; 171 (10): 685-694.

BackgroundThe potential role of new oral anticoagulants in antiphospholipid antibody syndrome (APS) remains uncertain.ObjectiveTo determine whether rivaroxaban is noninferior to dose-adjusted vitamin K antagonists (VKAs) for thrombotic APS.Design3-year, open-label, randomized noninferiority trial. (EU Clinical Trials Register: EUDRA [European Union Drug Regulatory Authorities] code 2010-019764-36).Setting6 university hospitals in Spain.Participants190 adults (aged 18 to 75 years) with thrombotic APS.InterventionRivaroxaban (20 mg/d or 15 mg/d, according to renal function) versus dose-adjusted VKAs (target international normalized ratio, 2.0 to 3.0, or 3.1 to 4.0 in patients with a history of recurrent thrombosis).MeasurementsThe primary efficacy outcome was the proportion of patients with new thrombotic events; the primary safety outcome was major bleeding. The prespecified noninferiority margin for risk ratio (RR) was 1.40. Secondary outcomes included time to thrombosis, type of thrombosis, changes in biomarker levels, cardiovascular death, and nonmajor bleeding.ResultsAfter 3 years of follow-up, recurrent thrombosis occurred in 11 patients (11.6%) in the rivaroxaban group and 6 (6.3%) in the VKA group (RR in the rivaroxaban group, 1.83 [95% CI, 0.71 to 4.76]). Stroke occurred more commonly in patients receiving rivaroxaban (9 events) than in those receiving VKAs (0 events) (corrected RR, 19.00 [CI, 1.12 to 321.9]). Major bleeding occurred in 6 patients (6.3%) in the rivaroxaban group and 7 (7.4%) in the VKA group (RR, 0.86 [CI, 0.30 to 2.46]). Post hoc analysis suggested an increased risk for recurrent thrombosis in rivaroxaban-treated patients with previous arterial thrombosis, livedo racemosa, or APS-related cardiac valvular disease.LimitationAnticoagulation intensity was not measured in the rivaroxaban group.ConclusionRivaroxaban did not show noninferiority to dose-adjusted VKAs for thrombotic APS and, in fact, showed a non-statistically significant near doubling of the risk for recurrent thrombosis.Primary Funding SourceBayer Hispania.

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