• antiphospholipid syndrome
• lupus erythematosus
• systemic
• therapeutics

2019 antiphospholipid syndrome (APS) guideline1 has been launched and has given recommendations to the rheumatologists on how to manage APS in different situations. The guideline has been presented in detail but there are still some questions remain to be discussed. For example, we are still confused in some circumstances, in secondary APS, such as systemic lupus erythematous, glucocorticoids (GC) is widely used. But according to the guideline in primary APS, GC treatment is recommended only in first trimester of pregnancy or in catastrophic APS (CAPS). But what about in second and third trimester of pregnancy? What dosage of GC is recommended? It needs more open discussion.

In terms of CAPS, the definition has a strict request on biopsy. Yet, in the clinic practice, there are little chance to do the biopsy. Besides, thrombosis happened in 1 week is also a criterion hard to meet; sometimes, it could happen in more than 1 week. Is it possible that in the future, the definition of CAPS will be modified? Although we could give the diagnose of probable CAPS in these cases, patients are still in danger and have a great risk of severe complications, whose treatment should be similar to CAPS. For instance, GC and plasma exchange need to be used. Furthermore, the guideline did not recommend the choice of disease-modifying antirheumatic drugs in severe cases, is there a preference? More studies are needed to answer this question as well.

Another circumstance is that patients with high-risk aPL profiles and new-onset thrombosis, besides heparin, is there a high-priority for GC and plasma exchange or intravenous immunoglobulins ? Moreover, in obstetric APS, another argument is that if a woman with positive medium–high titres of antiphospholipid antibodies, but with just once or twice spontaneous miscarriages (less than 10 weeks’ gestation), meaning not meeting the APS classification criteria, what should be done, to use aspirin or not? For these older pregnant women, it sounds like a disaster to have another miscarriage without any intervention. Maybe these questions need more evidence and more clear explanation from experts.