Blutungsmanagement unter direkten oralen Antikoagulanzien (DOAK)

Was ist neu?

Aktueller Stand Kein Gerinnungstest kann die Blutungswahrscheinlichkeit vorhersagen. Es lassen sich lediglich Pharmakokinetik und Momentaufnahme des Plasmaspiegels der DOAK messen. Zur Interpretation von Gerinnungstests ist es notwendig, u. a. den Zeitpunkt der letzten DOAK-Einnahme sowie die Organfunktionen von Niere und Leber zu kennen.

Der präoperative Notfallpatient Nicht zu verschiebende Operationen müssen ggf. auch unter wirksamen Spiegeln der DOAK durchgeführt werden, wobei aufgrund des Thromboembolierisikos und des nicht letztendlich gesicherten Wirksamkeitsnachweises derzeit von einer prophylaktischen Gabe von Faktorenkonzentraten abzuraten ist.

Behandlung von lebensbedrohlichen Blutungen unter DOAK-Therapie Vital bedrohliche Blutungen erfordern ein spezielles Hämostasemanagement. Als direkte Antidot-Therapie kann für Dabigatran das monoklonale Antikörperfragment Idarucizumab verabreicht werden, für die Xa-Inhibitoren steht PPSB (Prothrombinkomplexpräparat) zur Verfügung.

Abstract

Despite the widespread use of DOAC and recommendations of regulatory agencies and first consensus meetings on handling of bleeding situation under DOAC uncertainty still exists. In case of mild bleeding, the medical care of these patients and the delay of the next dose is advised. A laboratory analysis is indicated i. e. in case of known higher grade liver and kidney failure. The administration of factor concentrates or antidots is not indicated in this situation. In case of moderate to severe bleeding, the primary focus lies on stabilization of cardiopulmonary and circulatory function and parallel on the treatment depending on the localization of the bleeding source. In life-threatening bleeding in addition to the measures of hemodynamic stabilization a special haemostasis management may be required. In severe life-threatening bleeding treatment algorithms should be applied. In factor Xa-inhibitor-associated bleeding the use of factor concentrates (procoagulants), i. e. PCC in addition to unspecific measures, is indicated, as the direct antagonist andexanet alpha has not been approved in the EU. In contrast, the specific antagonist idarucizumab for acute dabigatran reversal is available in Germany.

Schlüsselwörter

DOAK - Rivaroxaban - Apixaban - Edoxaban - Dabigatran - Blutung - Blutungsmanagement

Key words

DOAC - rivaroxaban - apixaban - edoxaban - dabigatran - bleeding - bleeding management

• Literatur

• 1 Heidbuchel H, Verhamme P, Alings M. et al. Updated European Heart Rhythm Association (EHRA) practical guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17: 1467-1507
• 2 Caldeira D, Rodrigues F, Barra M. et al. Non-vitamin K antagonist oral anticoagulants and major bleeding-related fatality in patients with atrial fibrillation and venous thromboembolism: A systematic review and meta-analysis. Heart 2015; 101: 1204-1211
• 3 Ruff C, Giugliano R, Braunwald E. et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomised trials. Lancet 2014; 383: 955-962
• 4 Batchelor JS, Grayson A. A meta-analysis to determine the effect of anticoagulation on mortality in patients with blunt head trauma. Br J Neurosurg 2012; 26: 525-530
• 5 Wang Y, Bajorek B. New oral anticoagulants in practice: Phamacological and practical considerations. Am J Cardiovasc Drugs 2014; 14: 175-189
• 6 Cuker A, Siegal D, Crowther MA. et al. Laboratory measurements of the anticoagulant activity of the non-vitamin K oral anticoagulants. J Am Coll Cardiol 2014; 64: 1128-1139
• 7 Koscielny J, Rutkauskaite E. Blutungen unter NOAK: Evidenz und praktisches Vorgehen (Bleedings under NOAC (non Vitamin-K dependent oral anticoagulants): Evidence and practical management). Hämostaseologie 2015; 35: S43-S53
• 8 Maegele M, Grottke O, Koscielny J. Direct Oral Anticoagulants in Emergency Trauma Admissions. Dtsch Arztebl Int 2016; 113: 575-582
• 9 Faraoni D, Levy J, Albaladejo P. et al. Groupe d’Interet en Hemostase Perioperative. Updates in the perioperative and emergency management of non-vitamin K antagonist oral antocoagulants. Crit Care 2015; 19: 203
• 10 Koscielny J, Beyer-Westendorf J, von Heymann C. et al. „Risk of bleeding and haemorrhagic complication with rivaroxaban – periprocedural management of haemostasis“. Hamostaseologie 2012; 32: 287-293
• 11 Koscielny J, Rutkauskaite E. Bleedings under NOAC (non Vitamin-K dependent oral anticoagulants). Evidence and practical management. Hamostaseologie 2015; 35: S43-S53
• 12 Koscielny J, Rosenthal C, von Heymann C. et al. Update non Vitamin-K antagonist oral anticoagulants (DOACs): perioperative „switching“, drug interactions and Persistence. Hämostaseologie 2017; 37: 1-9