Besonderheiten der Antikoagulation bei adipösen Patienten

Zusammenfassung

Antikoagulanzien dienen der Prophylaxe und Therapie thromboembolischer Ereignisse. Indikationen wie stationäre und post-operative Prophylaxe bei bariatrischen Patienten sowie die wirksamen Dosierungen bei stark adipösen Patienten sind durch Zulassungsdaten nicht abgedeckt, die offiziellen Fachinformationen daher nur wenig hilfreich. Eine Unterdosierung von Antikoagulanzien kann das Thromboembolierisiko erhöhen oder die Wirksamkeit der Therapie reduzieren, eine Überdosierung das Risiko für Blutungen erhöhen. Standarddosierungen praktisch aller Antikoagulanzien führen bei stark adipösen Patienten zu einer reduzierten Medikamentenexposition. Dosierungen für Heparine und Fondaparinux sollten unter Beachtung substanzspezifischer Strategien erhöht werden. Die ohnehin notwendige INR-Kontrolle von Phenprocoumon/Warfarin macht spezifische Dosisempfehlungen unnötig. Für Dabigatran, Rivaroxaban und Apixaban liegen Daten zur Sicherheit und Wirksamkeit bei moderat adipösen Patienten vor, eine Dosisanpassung erscheint nicht notwendig. Stark adipöse Patienten wurden bislang nicht untersucht, der Einsatz der neuen Antikoagulanzien im Bereich malabsorptiver chirurgischer Eingriffe wird derzeit nicht empfohlen.

Summary

Thromboembolic events are prevented and treated by anticoagulants. Specific indications like pre- and post-surgery prevention in bariatric patients as well as choice of efficacious doses in massively obese patients are not covered by data submitted for approval. Thus, regularly official summaries of product characteristics information are not helpful. Underdosing of anticoagulants may increase the risk for thromboembolic events and decrease the efficacy of thrombosis treatment whereas overdosing might increase the bleeding risk. Administration of standard doses of nearly all anticoagulants results in decreased drug exposure. Heparin and fondaparinux doses therefore should be increased by substance-specific strategies. Phenprocoumon/warfarin require regular INR measurements in any case, specific dose recommendations are therefore not necessary. The safe and efficacious use of standard doses of dabigatran, rivaroxaban and apixaban in moderately obese patients is covered by clinical data, whereas massively obese patients were not studied. These new anticoagulants should not currently be used in patients undergoing malabsorptive bariatric surgery.

Schlüsselwörter

Heparin - niedermolekulares Heparin (NMH) - Fondaparinux - Phenprocoumon - Dabigatran - Rivaroxaban - Apixaban - Adipositas - bariatrische Chirurgie

Keywords

Heparin - low molecular weight heparin (LMWH) - fondaparinux - phenprocoumon - dabigatran - rivaroxaban - apixaban - obesity - bariatric surgery

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