How would you manage a patient with antiphospholipid syndrome in the setting of severe steroid-refractory thrombocytopenia?

Dr. @Dr. First Last answered the question of severe thrombocytopenia in a patient with APS and an acute thrombotic stroke. I agree with his approach. However, this “between a rock and a hard place” clinical scenario does also appear not infrequently during the chronic management of patients with APS, most especially with APS in the setting of SLE. There is a general agreement that to minimize bleeding risk while on warfarin and a therapeutic INR prefer the platelet count exceed 50,000. The first...

I would like some more information on the patient, such as age, bleeding history/risk, other cardiometabolic risk factors, other meds, etc. But in general, I agree with anticoagulation. Clearly, it would be helpful to get the platelet count up quickly--though even at 50,000 I would not hold anticoagulation if MRI shows no hemorrhage, and particularly if the strokes are multifocal, as they sometimes are in APS patients. Unfractionated heparin would be the agent of choice as it can be turned off q...