Question

A client with systemic lupus erythematous (SLE) begins to bleed excessively from her nose and mouth. The nurse suspects anti phospholipid syndrome. What actions should the nurse take? What physician’s orders should the nurse expect?

Answer 1

Medications.

In deciding whether to initiate anticoagulant prophylaxis for patients with antiphospholipid syndrome (APS), the benefits of these agents must be weighed carefully against their significant risks. Life-long treatment with warfarin ) is standard for patients who experience recurrent thrombotic events.

Heparin therapy may be administered in several regimens, as follows:

Thrombotic events are initially treated with intravenous infusion of unfractionated heparin or therapeutic doses of subcutaneous low molecular weight heparin (LMWH) and low-dose aspirin.

Subcutaneous LMWH (enoxaparin [Lovenox]) may also be used for obstetric or thrombosis prophylaxis. Lower doses (20-40 mg/d SC) are used to prevent fetal loss, while higher doses (1 mg/kg q12h or 1.5 mg/kg/d) are used for thrombosis prophylaxis in patients (pregnant or nonpregnant) who have had prior thrombotic events.

Patients who require heparin administration throughout pregnancy should receive calcium and vitamin D supplementation to help avoid heparin-induced osteoporosis. When monitoring heparin therapy, note that the activated partial thromboplastin time (aPTT) may be unreliable in the presence of circulating antiphospholipid (aPL) antibodies with a baseline elevated aPTT. In this case, factor Xa may be helpful.

Hydroxychloroquine has antithrombotic properties and may be considered in the prophylactic treatment of a patient with SLE and a positive aPL antibody test result.[19]The use of hydroxychloroquine and intravenous immunoglobulin (IVIG) has been associated with good outcomes in pregnant women with APS who develop recurrent episodes of thrombosis or catastrophic APS (CAPS) despite receiving adequate antithrombotic treatmentIn addition to full anticoagulation, plasma exchange and corticosteroids are generally used in the treatment of CAPS. IVIG or cyclophosphamide may be considered in selected patients with Caps.

Statins have been suggested to have potential antithrombotic effects. Statins are recommended for APS patients with hyperlipidemia and, possibly, in aPL patients with recurrent thromboses despite adequate anticoagulation.

Rituximab has shown benefit in controlling severe thrombocytopenia, skin ulcers, and cognitive dysfunction that can be associated with APS