Dabigatran in der Schlaganfallprävention bei Patienten mit Vorhofflimmern nach TIA oder ischämischem Insult: praktische Aspekte der Anwendung

Zusammenfassung

Dabigatran ist der erste direkte Thrombinantagonist, der zur Primär- und Sekundär-prophylaxe des ischämischen Schlaganfalls bei Patienten mit Vorhofflimmern zugelassen worden ist. In der Dosis von 2×110 mg ist Dabigatran genauso wirksam in der Verhinderung von Schlaganfällen und systemischen Embolien wie Warfarin (INR-Ziel 2.0–3.0), führt aber zu weniger schwerwiegenden Blutungen. In der höheren Dosis von 2×150 mg ist Dabigatran signifikant wirksamer als Warfarin bei einer gleichen Blutungsrate. Beide Dosierungen führen zu einer ca. 70%igen Reduktion zerebraler Blutungen. Die niedrigere Dabigatrandosis sollte bei Patienten >80 Jahre oder einem vorhersehbar erhöhten Blutungsrisiko eingesetzt werden. Die Prophylaxe mit Dabigatran kann nach einer TIA am selben Tag, nach leichtem bis mittelschwerem Schlaganfall innerhalb von 3–5 Tagen und nach schwerem Schlaganfall nach 10–14 Tagen begonnen werden. Die antikoagulatorische Wirkung ist bereits nach wenigen Stunden erreicht. Bei einer schweren Niereninsuffizienz (GFR <30 mL/min) ist Dabigatran kontraindiziert. Eine Einnahme von Dabigatran in den letzten 48 h ist eine Kontraindikation für eine systemische Thrombolyse mit rt-PA. Eine Verlängerung der aPTT kann ein Hinweis für eine Dabigatraneinnahme sein. Die Notfallbehandlung von intracraniellen Blutungen unter Dabigatran sollte mit Prothrombin-Komplexkonzentraten, Fresh Frozen Plasma oder rekombinantem Faktor VIIa erfolgen. Die Kombination von Dabigatran mit Thrombozytenfunktionshemmern erhöht das Blutungsrisiko und wird bei Patienten mit stabiler KHK nicht empfohlen. Die häufigste Nebenwirkung von Dabigatran sind gastrointestinale Beschwerden.

Abstract

Dabigatran is the first direct inhibitor of thrombin that has been approved for primary and secondary stroke prevention in patients with atrial fibrillation. The RELY Study showed that dabigatran given at a dose of 110 mg BID was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin (INR target 2.0 to 3.0), as well as lower rates of major haemorrhage. Dabigatran administered at a dose of 150 mg BID was significantly more effective compared to warfarin but showed a similar rate of major haemorrhage. Both dosages resulted in an approximately 70% reduction of intracerebral haemorrhages. The dosage of 110 mg BID should be preferably used in patients >80 years and with a higher bleeding risk. Treatment with dabigatran can be initiated immediately in patients with a TIA, 3–5 days after stroke onset in patients with minor stroke, and 10–14 days after stroke onset in patients with severe stroke. The anticoagulant effect of dabigatran is established within hours. Dabigatran is contraindicated in patients with severe renal impairment (creatinine clearance <30 mL/min). Patients who had been on dabigatran during the preceding 48 h should not be treated with systemic thrombolysis. The activated partial thromboplastin time may be prolonged under dabigatran. Intracerebral bleeding in patients taking dabigatran should be treated with prothrombin complex concentrates, fresh frozen plasma, or recombinant factor VII. The combination of dabigatran and platelet inhibitors increases the bleeding risk and is therefore not recommended in patients with stable coronary artery disease. The most common side effect of dabigatran is dyspepsia.

Schlüsselwörter

Vorhoffslimmern - Schlaganfall - Warfarin - Dabigatran - Blutungskomplikationen

Keywords

atrial fibrillation - stroke - warfarin - dabigatran - bleeding complications

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