In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?

I agree with Dr. @Dr. First Last. I have had patients with APS and recurrent thromboembolic events although not necessarily strokes to whom I have added aspirin and HCQ to the treatment regimen. I did this because she continued to have recurrent events. However, there is at least one article that negates the efficacy of aspirin, as we know. These are difficult patients. I remember one patient who in the face of full anticoagulation, aspirin, HCQ, no estrogens, and no smoking continued to have li...

This is a good question, especially noting the high rate of recurrent thrombotic events in non-treated patients with antiphospholipid syndrome (up to 29% if untreated, but still significant among treated patients, especially after an arterial event).

Edit: to jump to the punchline, I favor adding ASA to a VKA in these patients. Guidelines (notably EULAR, below) indicate that a VKA alone or a VKA + ASA are both reasonable options, and that there is a significant amount of uncertainty.

While the...

Agree with Dr. @Dr. First Last. There are limited data addressing this issue. The original guidelines published in Stroke a number of years back suggested that aspirin monotherapy was sufficient for secondary prophylaxis. However, most rheumatologists felt that was insufficient; especially since the patients were older with many co-morbidities. A recent meta-analysis by Bala et al., PMID 33045766, suggested that the addition of anti-platelet therapy to vitamin K inhibitors could possibly increas...

Anticoagulation should be sufficient.

No addition of ASA to "well anticoagulated" patient -- may need to assess Factor II activity to make sure it is less than 20% for adequate inhibition of hemostasis.

There have been so many attempts to use various "antiplatelet drugs" over the past 5 decades, in various thrombophilic conditions -- not successful, and associated with increased bleeding. Must have adequate inhibition of hemostasis only achievable with anticoagulation and not with antiplatelet drugs.

Agree with Drs. @Dr. First Last and @Dr. First Last about the increased risk of bleeding when adding aspirin to coumadin in patients with APS.

Add antiplatelet therapy