Nicht-Vitamin-K orale Antikoagulanzien in der Klinik

In den letzten Jahren werden NOAC zunehmend eingesetzt. Sie sind eine sichere und effektive Alternative zu den etablierten Vitamin-K-Antagonisten und weisen auch außerhalb der Studien weniger Blutungskomplikationen auf. Die wachsende Erfahrung mit den NOAC zeigt jedoch, dass noch Verbesserungsbedarf besteht und weitere Studien dringend erforderlich sind.

Kernaussagen

• NOAC sind eine sichere und wirksame Therapie für Patienten, bei denen eine Langzeit-Antikoagulation erforderlich ist. Sie haben im Vergleich zu Vitamin-K-Antagonisten seltener Nebenwirkungen, kaum Wechselwirkungen mit Nahrungsmitteln oder Medikamenten und bieten den Vorteil einer fixen Dosierung.

• Das Risiko für intrakranielle Blutungen ist bei NOAC um ca. 50 % geringer als bei Vitamin-K-Antagonisten.

• Die klassischen Gerinnungstests helfen nur bei einigen NOAC weiter.

• Für die Faktor-Xa-Inhibitoren ist die Situation noch schwieriger, da die meisten hilfreichen Testverfahren kaum verfügbar sind.

• Spezifische Point-of-Care-Tests für NOAC sind in der klinischen Prüfung.

• NOAC haben den Vorteil einer kurzen Halbwertszeit, weshalb bei leichten Blutungen eine abwartende Haltung und ggf. das zeitweilige Aussetzen der Medikation gerechtfertigt ist. Bei schweren Blutungen ist dagegen eine möglichst schnelle Wiederherstellung der Hämostase anzustreben.

• Bei lebensbedrohlichen Blutungen oder nicht aufschiebbaren Eingriffen unter Dabigatran sollte man Idarucizumab in einer Dosierung von 5 g i. v. verabreichen.

• Bei lebensbedrohlichen Blutungen oder nicht aufschiebbaren Eingriffen unter Faktor-Xa-Antagonisten sollte man die Gabe von PPSB (30 – 50 U/kgKG) erwägen.

• Die Einnahme von Aktivkohle ist nach kurz zurückliegender Einnahme des Medikaments für alle Faktor-Xa-Inhibitoren eine Therapiemöglichkeit. Spezifische Antidota (Andexanet Alpha oder PER 977) sind in der klinischen Entwicklung.

• Alle Patienten mit oraler Antikoagulationstherapie (Vitamin-K-Antagonisten und NOAC) sollten immer einen Notfallausweis bei sich tragen.

• Literatur

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