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Management von Blutungen unter Therapie mit direkten oralen Antikoagulanzien

Management of hemorrhage in patients treated with direct oral anticoagulants

  • Klinische Pharmakologie
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Zusammenfassung

Die Einführung der „nicht-Vitamin-K-abhängigen“, direkten oralen Antikoagulanzien (DOAK) bewirkte eine Vereinfachung der thrombembolischen Prävention für die Patienten. Auf ärztlicher Seite herrscht allerdings zum einen immer noch eine große Unsicherheit im Rahmen des prä- und postoperativen Ab- und Wiederansetzens der Antikoagulation. Zum anderen erfordern Blutungen unter DOAK-Therapie spezifische Kenntnisse hinsichtlich diagnostischer und therapeutischer Optionen.

Bisherige Therapiestrategien basierten vornehmlich auf Expertenempfehlungen und waren im Rahmen von Plasmasubstitution oder der Verwendung von Faktorenpräparaten relativ unspezifisch. Zudem muss davon ausgegangen werden, dass bei der Verwendung von prokoagulatorischen Substanzen, wie Prothrombinkomplex-Konzentrat (PPSB), das thrombogene Risiko nach erfolgter Therapie potenziell ansteigt. Ein neuer Ansatz resultiert aus der Einführung von Idarucizumab, das als spezifisches, schnell wirkendes und gerinnungsinertes Antidot für den Thrombininhibitor Dabigatran zur Verfügung steht.

Die vorliegende Übersichtsarbeit soll einen Überblick über pharmakologische Daten, Möglichkeiten der Therapie DOAK-assoziierter Blutungen und spezifische Reversierungsmöglichkeiten geben.

Abstract

The introduction of nonvitamin K antagonistic, direct oral anticoagulants (DOAC) made thromboembolic prophylaxis easier for patients. For many physicians, however, there is still uncertainty about monitoring, preoperative discontinuation, and restarting of DOAC therapy. Guidelines for the management of bleeding are provided, but require specific therapeutic skills in the management of diagnostics and therapy of acute hemorrhage. Small clinical studies and case reports indicate that unspecific therapy with prothrombin complex concentrates (PCC) and activated PCC (aPCC) concentrate may reverse DOAC-induced anticoagulation. However, PCC or aPCC at higher doses potentially provoke thromboembolic complications. However, idarucizumab, a specific, fast-acting, antidote for dabigatran, provides immediate and sustained reversal with no intrinsic or prohemostatic activity. This review article provides an overview of the pharmacology and potential risk of DOAC and the management in the perioperative period with a focus of current concepts in the treatment of DOAC-associated bleeding.

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Authors and Affiliations

  1. Klinik für Anästhesiologie, Experimentelle Hämostaseologie, Universitätsklinikum RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland

    O. Grottke MPH

  2. Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Köln, Deutschland

    H. Lier

  3. Klinik für Anästhesie, Intensiv- und Notfallmedizin, Westpfalz-Klinikum GmbH, Kaiserslautern, Deutschland

    S. Hofer

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  3. S. Hofer
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Correspondence to O. Grottke MPH.

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Interessenkonflikt

O. Grottke erhielt Studienförderung von Bayer Healthcare, Boehringer Ingelheim, Biotest, CSL Behring, Novo Nordisk, Nycomed und Portola sowie Vortragshonorare für wissenschaftliche Referate bzw. Beratertätigkeiten von CSL Behring, Boehringer Ingelheim, Bayer, Baxalta, Pfizer, Portola, Octapharma und Sanofi. H. Lier erhielt Vortragshonorare und Reisekostenerstattungen von Bayer Vital, Blutspendedienst West (DRK), CSL Behring, Ferring, Mitsubishi Pharma, NovoNordisk, Tem International. S. Hofer erhielt Vortragshonorare von CSL Behring, Boehringer Ingelheim, Novo Nordisk; Tem International und Bayer.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Grottke, O., Lier, H. & Hofer, S. Management von Blutungen unter Therapie mit direkten oralen Antikoagulanzien. Anaesthesist 66, 679–689 (2017). https://doi.org/10.1007/s00101-017-0313-5

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