Perioperative Thromboseprophylaxe – Neue orale Antikoagulanzien und ihre Anwendung im Umfeld operativer Eingriffe

Zusammenfassung

Neue orale Antikoagulanzien (NOACs) sind zugelassen zur VTE-Prophylaxe in der Gelenkersatzchirurgie, zur Behandlung von venöser Thromboembolie und zur Schlaganfallprophylaxe bei Vorhofflimmern. Der Thrombininhibitor Dabigatran hat mit 11–14h die längste Halbwertszeit, die sich bei Niereninsuffizienz bedeutsam verlängert Die anti-Xa-Hemmstoffe Rivaroxaban und Apixaban haben geringfügig kürzere Halbwertszeiten und werden nur zu ca. 30% renal eliminiert. Vor elektiven Eingriffen sind Behandlungspausen einzulegen, die auf die aktuellen Halbwertszeiten Rücksicht nehmen. Eine überbrückende Antikoagulation ist nicht erforderlich. Das Blutungsmanagement unter NOACs unterscheidet sich nicht vom Vorgehen unter anderen Gerinnungshemmstoffen, das Fehlen von Antidota wird praktisch kein großes Problem darstellen. Die größten Unsicherheiten werden dadurch entstehen, dass NOACs die Globaltests der Gerinnung verändern, ohne dass dies Rückschlüsse auf die Intensität der Antikoagulation zulässt.

Abstract

Novel oral anticoagulants (NOACs) have become available for prevention of venous thromboembolism after major orthopaedic surgery, treatment of venous thromboembolism, and stroke prevention in patients with atrial fibrillation. The thrombin inhibitor Dabigatran has a plasma half life of 11-14 hours which prolongs significantly in renal insufficiency. The two Xa-inhibitors Rivaroxaban and Apixaban have slightly shorter half lifes, and renal elimination is confined to about 30% of active drug. Prior to elective surgery, drug intake needs to be halted. The time period depends on the actual drug half life in that particular situation. Bridging anticoagulation is not necessary. The management of bleeding complications does not differ from that in other anticoagulants. The most uncertainties in clinical practice will arise from the fact that NOACs derange the global clotting tests without any conclusive information about the actual intensity of anticoagulation.

Schlüsselwörter:

neue orale Antikoagulanzien - Dabigatran - Rivaroxaban - Apixaban - perioperatives Management

Key words:

new oral anticoagulants - Dabigatran - Rivaroxaban - Apixaban - perioperative anticoagulation management

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