Biomedical Sciences, Biomed Biopharm Res., 2022; 19(2):1-6
Antiphospholipid Syndrome (Clinical case)
Bruno Sousa 1,2,3
1School of Sciences and Health Technologies, Universidade Lusófona de Humanidades e Tecnologias, Lisboa, Portugal
2CBIOS – Universidade Lusófona's Research Center for Biosciences and Health Technologies, Lisboa, Portugal
3Health Service of Autonomous Region of Madeira, Madeira, Portugal
40-year-old woman, unemployed. She sought Nutrition Consultation for nutritional control, as she was taking oral anticoagulant therapy. No other pathologies requiring nutritional therapy, but she wanted to lose a little weight.
She is followed in the Thrombophilia Consultation for Antiphospholipid Syndrome (APS) for mutation of the prothrombin gene in heterozygosity. She takes warfarin as an oral anticoagulant, with INR (International Normalized Ratio) control.
Keywords: International Normalized Ratio, nutritional intervention, vitamin K, Antiphospholipid Syndrome, warfarin
Received: 11/08/2022; Accepted: 30/10/2022
Weight: 58.6 kg
Height: 157 cm
BMI: 23.8 kg/m2
Waist circumference: 76 cm
Body composition assessment (TANITA TBF 300®)
Body fat: 27.5%
Fat mass: 16.1 kg
Fat-free mass: 42.5 kg
Total body water: 31.1 kg
Leukocytes: 4.9 10^3/μL (4.2 – 10.8)
Erythrocytes: 4.83 10^6/μL (3.91 – 5.07)
Hemoglobin: 13.3g/dL (11.9 – 14.9)
Hematocrit: 38.9% (34.0 - 44.0)
Platelets: 226.0 10^3/μL (144 – 440)
Prothrombin time: 31.0 sec (9.4-12.5)
INR: 2.62 (0.9-1.2)
PTT seg: 43seg (25-37)
Fibrinogen: 217.0mg/dl (200.0 – 393.0)
Lupus antic. – Ratio: 0,99 (<=1,20)
Silica Clotting Time – Ratio: 0,99 (<=1.16)
Glucose: 96 mg/dL (74.0 - 106.0)
Urea: 17 mg/dL (16.6 – 48.5)
Creatinine: 0.61 mg/dL (0.50 – 0.90)
Sodium: 138.0 mEq/L (136 - 145)
Potassium: 3.90 mEq/L (3.5 – 5.10)
Chlorine: 102.0 mEq/L (98-107)
Total cholesterol: 178 mg/dL (<200.0)
HDL cholesterol: 56.0 mg/dL (>45.0)
LDL cholesterol: 99.4 mg/dL (<100.0)
Triglycerides: 113.0 mg/dL (<150.0)
Alanine Aminotransferase: 16.9 U/L (<=33)
Aspartate Aminotransferase: 15.0 U/L (<=32)
Gamaglutamyltransferase: 6.0 U/L (5.0 – 36.0)
Anti-nuclear antibodies (ANA): Negative
Screen ENA’s: 0.3 (<10)
Ac. Anti-dsDNA, IgG: 0.0 GPL/mL (<10)
Ac. Anti-cardiolipinas, IgG: 0.0 GPL/mL (<10)
Ac. Anti-cardiolipinas, IgM: 7.0 MPL/mL (<10)
Ac. Anti-Beta-2 Glicoproteína I, IgG: 0.0 UA/mL (<10)
Ac. Anti-Beta-2 Glicoproteína I, IgM: 11.4 UA/mL (<10)
- Prothrombin gene mutation in heterozygosity
- Repeat abortions (2nd trimester fetal death + abortion at 6th week of pregnancy)
- Has one 9 year old child and another four months old
Warfarin (variable - depending on INR)
Intestinal transit: regular
Wake up at 8 am
Lunch: 2 pm
Dish: Half a plate of white rice or pasta + meat or fish (120 g) + vegetables (about 100 g)
Dessert: 1 medium piece of fruit
Water to drink
Afternoon snack: 5 pm
1 medium piece of fruit
1 plain or flavoured yoghurt
4 tablespoons of oat flakes
Dinner: 8:30 pm
Identical to lunch
Goes to bed at 11 pm
Water consumption: approximately 1.5 litres per day
Alcohol habits: Sporadic use at parties
Smoking habits: Does not smoke
Environment, behaviour and social
She is married and lives with her husband and two children.
She spends most of her time at home, where she has most of her meals, but mentions that she also has some social gatherings, where the food offered is more diverse. On weekends, she has some meals in restaurants.
She likes sweets and mentions that she takes care with the preparation of food, opting for a healthy preparation.
She is sedentary, although she does go for some walks, but not routinely.
1. What is Antiphospholipid Syndrome?
2. What is the treatment for Antiphospholipid Syndrome?
3. In cases where warfarin is the treatment, should there be restrictions on the intake of food rich in vitamin K?
4. What is the role of the Nutritionist in these patients treated with warfarin?
5. Is a diet rich in calcium important in the nutritional intervention for this syndrome?
The author wishes to express his thanks to the patient who allowed the elaboration of the case study.
Conflict of Interests
The author declares there are no financial and personal relationships that could present a potential conflict of interests.
1. It is an autoimmune disease caused by autoantibodies directed against one or more proteins linked to phospholipids: lupus anticoagulant, anti-cardiolipin, or beta-2 glycoprotein I. The most frequent clinical manifestations include deep venous thrombosis of the lower limbs, pulmonary embolism, early and late spontaneous abortions, clinical features of arthritis, and migraine.
2. For prophylaxis and treatment, anticoagulation is used: heparin, warfarin (except in pregnant women) or antiaggregation: acetylsalicylic acid. The choice of therapy depends on the clinical manifestations and the type of antibodies and obstetric morbidity.
3. In these cases, the consumption of foods particularly rich in vitamin K is not forbidden, but must be moderate. The fundamental point is to maintain a balanced diet, constant over time, with no need for severe restrictions.
In patients with other pathologies that require dietary therapy and who benefit from an increased intake of fruit and vegetables, there is no justification for their restriction, as it is important for the treatment of the disease and to avoid micronutrient deficiencies, without influencing the control of hypocoagulation.
4. The Nutritionist is very important in these situations and should play a very active role in monitoring patients from the beginning of this therapy. His or her intervention involves dietary education and the indication of an adequate diet, with a regular and daily content of vitamin K sources, to circumvent the effect of seasonality, and thus contribute to better stability of the anticoagulant therapy.
5. A diet rich in calcium is also important, as these patients on heparin or warfarin have a higher risk of osteoporosis or osteopenia.
1. Domingues, B., Cardoso, F., Rodrigues, T. (2019). Alimentação e Hipocoagulação Oral. Porto: Associação Portuguesa de Nutricionistas.
2. Klack, K., Carvalho, J.F. (2013). Dietetic issues in antiphospholipid syndrome. Rheumatology International, 33(3), 823–824. https://doi.org/10.1007/s00296-011-2313-0.
3. Lim, W., Crowther M.A., Eikelboom, J.W. (2006). Management of Antiphospholipid Antibody Syndrome - A Systematic Review. JAMA. 295(9), 1050–1057. https://doi.org/10.1001/jama.295.9.1050.
4. Miyakis, S., Lockshin, M.D., Atsumi, T., Branch, B.W., Brey, R.L., Cervera, R., Derksen, R.H.W.M., DE Groot, P.G., Koike, T., Meroni, P.L., Reber, G., Shoenfeld, Y., Tincani, A., Vlachoyiannopoulos, P.G., Krilis, S.A. (2006). International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). Journal of thrombosis and haemostasis : JTH, 4(2), 295–306. https://doi.org/10.1111/j.1538-7836.2006.01753.x
5. Negrini, S., Pappalardo, F., Murdaca, G., Indiveri, F., Puppo, F.(2017). The antiphospholipid syndrome: from pathophysiology to treatment. Clinical and experimental medicine, 17(3), 257–267. https://doi.org/10.1007/s10238-016-0430-5
6. Ruiz-Irastorza, G,, Crowther, M., Branch, W., Khamashta, M.A.(2010). Antiphospholipid syndrome. Lancet, 30;376(9751:1498-509. doi: 10.1016/S0140-6736(10)60709-X.
7. Santos, L, Figueiredo, L. Fonseca, F. (2006). Vitamina K e antigcoagulantes orais. Nutricias, 5 :33-35.
8. Tektonidou, M.G,, Andreoli, L., Limper, M., Amoura, Z., Cervera, R., Costedoat-Chalumeau, N., Cuadrado, M.J., Dörner, T., Ferrer-Oliveras, R., Hambly, K., Khamashta, M.A., King, J., Marchiori, F., Meroni, P.L., Mosca, M., Pengo, V., Raio, L., Ruiz-Irastorza, G., Shoenfeld, Y., Stojanovich, L., Svenungsson, E., Wahl, D., Tincani, A., Ward, M.M.(2019). EULAR recommendations for the mangement of antiphospholipid syndrome in adults. Annals of the rheumatic diseases, 78(10), 1296–1304. https://doi.org/10.1136/annrheumdis-2019-215213.