How would you manage a patient with SLE that has a remote history of positive anti-phospholipid antibodies with a current DVT and now completely negative APLs?

Assuming the reliability of the lab report indicating negative antiphospholipid antibodies (APL) and the absence of any other manifestations as per the latest APLS guidelines, I generally would not factor a distant history of APL positivity when determining the management of this patient.

While the factors mentioned below may not significantly alter my decision, additional information on the current deep vein thrombosis (DVIT), such as whether it is provoked or unprovoked, family history, traditional risk factors, presence of nephrotic syndrome, comorbidities, and recent infections, would enhance the certainty of my decision and facilitate a more detailed discussion with the patient.

Further details about the prior history of APL positivity, such as whether it was reported or documented, the degree of positivity (low versus high), and the status of lupus anticoagulant (LAC), would also be valuable.

Various factors can lead to the disappearance of APL antibodies, including their transient occurrence after viral infections, h. pylori, acute strokes or myocardial infarction. There are reports of disappearance linked to medications like hydroxychloroquine, corticosteroids, anakinra, belimumab, and even discontinuation of certain drugs like minocycline.

While there is no conclusive evidence supporting primary prevention in patients with transient APL antibodies, it is important to note that long-term thrombosis risk in these individuals has not been extensively studied. Retrospective studies indicate that a substantial percentage (~20%) of APLS patients may become APL negative after approximately 6 years of follow-up, and some suggest a potential recurrence of thrombosis with or without anticoagulation (referenced below). However, this is a different scenario that is not applicable to the patient in question.

References:

• Ballul et al., PMID 36774700
• Medina et al., PMID 28216071
• Comarmond et al., PMID 28355985