Management of bleeding in patients using antithrombotic agents

Summary

Antiplatelet agents and anticoagulants are effective in the prevention and treatment of a variety of thrombotic disorders. Several clinical settings require more intense antithrombotic regimens. These can be provided by combining (i) two antiplatelet drugs, (ii) anti-platelet monotherapy with an anticoagulant, or (iii) anticoagulation with dual antiplatelet treatment (triple therapy). A major side effect of all antithrombotic regimens, however, is the induction of a bleeding diathesis. This is especially true in patients with preexisting haemostatic defects of any kind that may remain compensated, unless platelet function and/or coagulation are not inhibited pharmacologically. To address the dilemma of the “double-edged sword” between thrombosis and bleeding, several strategies are currently under study, including (i) identification of high-risk patients, (ii) stratification of patient subgroups, (iii) individualized decision making, and (iv) administration of “tailor-made” risk-adapted regimens. Nonetheless, prevention and protection from bleeding in patients using antithrombotic agents remain an enduring challenge. For high-risk patients on antiplatelet agents with urgent need of surgery, an algorithm is discussed that allows short-term interruption of oral antithrombotic therapy and i.v. administration of a GPIIb-IIIa receptor antagonist for bridging without increasing peri-operative bleeding. When individual patients, using antiplatelet or anticoagulant agents, experience serious or even life-threatening haemorrhages, haemotherapy with platelet units or prothrombin complex concentrates remains an integral part of the clinical management.

Zusammenfassung

Plättchenfunktionshemmende Substanzen und Antikoagulanzien sind wirksam zur Prävention und Behandlung einer Vielzahl thrombotischer Krankheitsbilder. Verschiedene klinische Situationen erfordern gleichwohl intensivierte anti-thrombotische Therapiekonzepte. Optionen hierfür ergeben sich aus der Kombination von (i) zwei antithrombozytären Substanzen, (ii) antithrombozytärer Monotherapie mit einem Antikoagulans oder (iii) Antikoagulation mit dualer Plättchenfunktionshemmung (Triple-Therapie). Die unter antithrombotischen Behandlungsregimen auftretende Blutungsneigung stellt freilich eine erhebliche Nebenwirkung dar. Dies gilt vor allem für Patienten mit bereits vorhandenen Hämostasestörungen jeglicher Art, die oft kompensiert bleiben können, solange keine pharmakologische Hem-mung von Plättchen und/oder Gerinnung induziert wird. Um dem Dilemma dieses ,,zweischneidigen Schwerts“ mit Thrombose und Blutung zu begegnen, werden derzeit verschiedene Strategien verfolgt: (i) Identifizie-rung von Hochrisiko-Patienten, (ii) Stratifizie-rung von Untergruppen, (iii) individualisierte Entscheidungsprozesse und (iv) ,,maß-geschneiderte“ risikoadaptierte Therapiemaßnahmen. Im Hinblick auf Blutungen bei antithrombotischer Behandlung bleiben Prävention und Protektion gleichwohl eine dauerhafte Herausforderung. Für Hochrisiko-Patienten unter antithrombozytärer Medikation, die sich einer dringlichen Operation zu unterziehen haben, wird ein Algorithmus vorgeschlagen, der eine nur kurzfristige Unterbrechung der oralen antithrombotischen Behandlung und die i.v. Gabe eines GPIIb-IIIaRezeptor-Antagonisten zur Überbrückung vorsieht, ohne das perioperative Blutungsrisiko zu erhöhen. Treten bei einzelnen Patienten während der Einnahme plättchenfunktionsbzw. gerinnungshemmender Medikamenten schwerwiegende, gar lebensbedrohliche Blutungen auf, bleibt die Hämotherapie mit Thrombozyten- bzw. ProthrombinkomplexKonzentraten unverzichtbarer Bestandteil der Behandlung.

Keywords

Antiplatelet drugs - vitamin K antagonists - haemostasis monitoring - clinical trials - platelet transfusions - coagulation factor concentrates

Schlüsselwörter

Antithrombozytäre Substanzen - Vitamin-K Antagonisten - Hämostase-Monitoring - klinische Studien - Thrombozytentransfusionen - Gerinnungsfaktoren-Konzentrate

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