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Neue orale Antikoagulanzien in der perioperativen Medizin

New oral anticoagulants in perioperative medicine

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An Erratum to this article was published on 05 June 2014

Zusammenfassung

Die neuen oralen Antikoagulanzien (NOAK) hemmen direkt den Faktor Xa (Stuart-Prower-Faktor) oder den Faktor IIa (Thrombin). Sie werden zur Thromboseprophylaxe bei elektivem Hüft- oder Kniegelenkersatz, zur Therapie der tiefen Venenthrombose und zur Schlaganfallprophylaxe bei Vorhofflimmern als Behandlungsalternative zu den Vitamin-K-Antagonisten eingesetzt. Patienten mit langfristiger NOAK-Einnahme stellen alle Beteiligten in der perioperativen Phase vor medizinisch-logistische Herausforderungen. Bei geplanten Operationen ist zur individuellen Festlegung der perioperativen hämostaseologischen Strategie, insbesondere des optimalen Operationszeitpunkts, die frühzeitige Vorstellung der Patienten beim Anästhesisten zu fordern. Die zeitliche Dringlichkeit bei „Notoperationen“ muss interdisziplinär gegen das Blutungsrisiko unter NOAK abgewogen werden. Die Bestimmung der Medikamentenspiegel erlaubt hierbei eine Abschätzung der aktuellen Antikoagulation. Ursächlich koagulopathisch bedingte Blutungsnotfälle werden mit Blutprodukten und Gerinnungsfaktorenkonzentraten unspezifisch therapiert.

Abstract

New oral anticoagulants (NOAC) inhibit factor Xa (Stuart-Prower factor) or factor IIa (thrombin) and are alternatives to vitamin K antagonists. Perioperative indications are deep vein thrombosis prophylaxis for prosthetic hip and knee replacement, therapeutic anticoagulation for deep vein thrombosis as well as the prophylaxis of stroke for patients with atrial fibrillation. Patients on NOACs pose multiple perioperative challenges for all medical disciplines involved. For non-emergency surgery, patients should be evaluated by an anesthesiolgist as early as possible to assess an optimal appointment for surgery and bridging strategy. Management of emergency procedures for patients on NOACs requires an interdisciplinary approach. The individual risk for uncontrolled bleeding versus the urgency for surgery needs to be evaluated on an individual basis. The determination of drug serum levels enables a rough estimation of anticoagulant activity. Emergency procedures in coagulopathy due to active bleeding are treated with the unspecific administration of blood products and coagulation factor concentrates.

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Literatur

  1. Mueck W, Eriksson BI, Bauer KA et al (2008) Population pharmacokinetics and pharmacodynamics of rivaroxaban – an oral, direct Factor Xa inhibitor – in patients undergoing major orthopaedic surgery. Clin Pharmacokinet 47:203–216

    Article  CAS  PubMed  Google Scholar 

  2. Stangier J, Rathgen K, Stähle H et al (2007) The pharmacokinetics, pharmacodynamics and tolerability of dabigatran etexilate, a new oral direct thrombin inhibitor, in healthy male subjects. Br J Clin Pharmacol 64:292–303

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Frost C, Wang J, Nepal S et al (2013) Apixaban, an oral, direct factor Xa inhibitor: single dose safety, pharmacokinetics, pharmacodynamics and food effect in healthy subjects. Br J Clin Pharmacol 75:476–487

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  4. Schlitt A, Jámbor C, Spannagl M et al (2013) Perioperativer Umgang mit Antikoagulanzien und Thrombozytenaggregationshemmern. Dtsch Arztebl Int 110:525–532

    PubMed Central  PubMed  Google Scholar 

  5. Fachinformation Clexane®, Juli 2013

  6. Fachinformation Pradaxa®, August 2013

  7. Fachinformation Xarelto®, Juli 2013

  8. Ryn J van, Stangier J, Haertter S et al (2010) Dabigatran etexilate – a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 103:1116–1127

    Article  PubMed  Google Scholar 

  9. Sibbing D, Spannagl M (2014) Direkte orale Antikoagulanzien und Thrombozytenfunktionshemmer, Klinische Relevanz und Möglichkeiten der Labordiagnostik. Haemostaseologie 34:78–84

    Article  CAS  Google Scholar 

  10. Fachinformation Eliquis®, September 2013

  11. Tripodi A (2013) The laboratory and the new oral anticoagulants. Clin Chem 59:353–362

    Article  CAS  PubMed  Google Scholar 

  12. Kubitza D, Haas S (2006) Novel factor Xa inhibitors for prevention and treatment of thromboembolic diseases. Expert Opin Investig Drugs 15:843–855

    Article  CAS  PubMed  Google Scholar 

  13. Kubitza D, Becka M, Voith B et al (2005) Safety, pharmacodynamics, and pharmacokinetics of single doses of BAY 59–7939, an oral, direct factor Xa inhibitor. Clin Pharmacol Ther 78:412–421

    Article  CAS  PubMed  Google Scholar 

  14. Haas S (2009) Rivaroxaban – an oral, direct Factor Xa inhibitor: lessons from a broad clinical study programme. Eur J Haematol 82:339–349

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  15. Barrett YC, Wang Z, Frost C, Shenker A (2010) Clinical laboratory measurement of direct factor Xa inhibitors: anti-Xa assay is preferable to prothrombin time assay. Thromb Haemost 104:1263–1271

    Article  CAS  PubMed  Google Scholar 

  16. Douxfils J, Mullier F, Robert S et al (2012) Impact of dabigatran on a large panel of routine or specific coagulation assays. Laboratory recommendations for monitoring of dabigatran etexilate. Thromb Haemost 107:985–997

    Article  CAS  PubMed  Google Scholar 

  17. Koscielny J, Beyer-Westendorf J, Heymann C von et al (2012) Risk of bleeding and haemorrhagic complication with rivaroxaban – periprocedural management of haemostasis. Haemostaseologie 32:287–293

    Article  CAS  Google Scholar 

  18. Spannagl M, Bauersachs R, Debus ES et al (2012) Therapie mit Dabigatran, Periinterventionelles Management und Interpretation von Gerinnungstests. Haemostaseologie 32:294–305

    Article  CAS  Google Scholar 

  19. Reilly PA, Lehr T, Haertter S et al (2014) The effect of dabigatran plasma concentrations and patient characteristics on the frequency of ischemic stroke and major bleeding in atrial fibrillation patients. The RE-LY Trial (Randomized Evaluation of Long-Term Anticoagulation Therapy). J Am Coll Cardiol 63:321–328

    Article  CAS  PubMed  Google Scholar 

  20. Pernod G, Albaladejo P, Godier A et al (2013) Management of major bleeding complications and emergency surgery in patients on long-term treatment with direct oral anticoagulants, thrombin or factor-Xa inhibitors: proposals of the working group on perioperative haemostasis (GIHP). Arch Cardiovasc Dis 106:382–393

    Article  PubMed  Google Scholar 

  21. Samama M, Contant G, Spiro TE et al (2013) Laboratory assessment of rivaroxaban: a review. Thromb J 11:11

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  22. Rolin HA III, Hall PM, Wei R (1984) Inaccuracy of estimated creatinine clearance for prediction of iothalamate glomerular filtration rate. Am J Kidney Dis 4:48–54

    Article  PubMed  Google Scholar 

  23. Waller DG, Fleming JS, Ramsay B, Gray J (1991) The accuracy of creatinine clearance with and without urine collection as a measure of glomerular filtration rate. Postgrad Med J 67:42–46

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  24. Dalton RN (2010) Serum creatinine and glomerular filtration rate: perception and reality. Clin Chem 56:687–689

    Article  CAS  PubMed  Google Scholar 

  25. Sié P, Samama CM, Godier A et al (2011) Surgery and invasive procedures in patients on long-term treatment with direct oral anticoagulants: thrombin or factor-Xa inhibitors. Recommendations of the Working Group on Perioperative Haemostasis and the French Study Group on Thrombosis and Haemostasis. Arch Cardiovasc Dis 104:669–667

    Article  PubMed  Google Scholar 

  26. Darius H, Bosch R, Hindricks G et al (2012) Focused update of the ESC Guidelines for the management of patients with atrial fibrillation. Eur Heart J 33:2719–2747

    Article  Google Scholar 

  27. Mason PK, Lake DE, DiMarco JP et al (2012) Impact of the CHA2DS2-VASc Score on anticoagulation recommendations for atrial fibrillation. Am J Med 125:603e1–603e6

    Article  Google Scholar 

  28. Heidbuchel H, Verhamme P, Alings M et al (2013) Practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Eur Heart J 27:1–13

    Google Scholar 

  29. Hoffmeister HM, Bode C, Darius H et al (2010) Unterbrechung antithrombotischer Behandlung (Bridging) bei kardialen Erkrankungen (Positionspapier). Kardiologe 4:365–374

    Article  CAS  Google Scholar 

  30. Birnie DH, Healey JS, Wells GA et al (2013) Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med 368:2084–2093

    Article  CAS  PubMed  Google Scholar 

  31. Rosencher N, Bonnet MP, Sessler DI (2007) Selected new antithrombotic agents and neuraxial anaesthesia for major orthopaedic surgery: management strategies. Anaesthesia 62:1154–1160

    Article  CAS  PubMed  Google Scholar 

  32. Gogarten W, Vandermeulen E, Van Aken H et al (2010) Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 27:999–1015

    Article  CAS  PubMed  Google Scholar 

  33. Benzon HAT, Avram MJ, Green D, Bonow RO (2013) New oral anticoagulants and regional anaesthesia. Br J Anaesth 111:96–113

    Article  Google Scholar 

  34. Spahn DR, Borgeat A, Ravussin P et al (2013) Expertengruppe „Rivaroxaban and anesthesiology“, „Dabigatran and anesthesiology“, „Apixaban and anesthesiology“. http://www.sgar-ssar.ch/anaesthesie/informationen-zu-medikamenten/

  35. Harrop-Griffiths W, Cook T, Gill H et al (2013) Regional anesthesia and patients with abnormalities of coagulation. Anaesthesia 9:966–972

    Google Scholar 

  36. Kaatz S, Kouides PA, Garcia DA et al (2012) Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. Am J Hematol 87:141–145

    Article  Google Scholar 

  37. Anonymus (2013) Die Hersteller neuen Antikoagulantien warnen vor Blutungen und unsachgemäßem Gebrauch. Arzneimittelbrief 47, Nr.10

  38. Cushman M (2013) Treating acute venous thromboembolism – shift with care. N Engl J Med 369:865–866

    Article  CAS  PubMed  Google Scholar 

  39. Nutescu E, Wittkowsky AK, Burnett A et al (2013) Delivery of optimized inpatient anticoagulation therapy: consensus statement from the anticoagulation forum. Ann Pharmacother 47:714–724

    Article  PubMed  Google Scholar 

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Einhaltung ethischer Richtlinien

Interessenkonflikt. K. Gürtler: Vortrag für Bayer zum Thema Thromboseprophylaxe mit Rivaroxaban. A. Giebl gibt an, dass kein Interessenkonflikt besteht. Der Beitrag enthält keine Studien an Menschen oder Tieren.

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Giebl, A., Gürtler, K. Neue orale Antikoagulanzien in der perioperativen Medizin. Anaesthesist 63, 347–364 (2014). https://doi.org/10.1007/s00101-014-2314-y

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