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Vitamin-K-Antagonisten

Ist ihre Verordnung heute wirklich ein „Kunstfehler“?

Vitamin K antagonists

Is their prescription really “medical malpractice” today?

  • Arzneimitteltherapie
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Zusammenfassung

Vorhofflimmern und venöse Thrombembolien zählen zu den häufigsten kardiovaskulären Erkrankungen. Zur Primär- und Sekundärprophylaxe von thrombembolischen Ereignissen dient die orale Antikoagulation. Hierfür standen bis vor wenigen Jahren nur Vitamin-K-Antagonisten (VKA) zur Verfügung. Aktuell sind die nicht-Vitamin-K-abhängigen Antikoagulanzien (neue orale Antikoagulanzien [NOAK]) Dabigatran, Rivaroxaban, Apixaban und Edoxaban zugelassen. Sowohl die Zulassungsstudien für NOAK als auch Metaanalysedaten und Daten aus Registern weisen auf Vorteile der NOAK gegenüber VKA hin, im Sinne einer Reduktion von Thrombembolien und einer Reduktion von Blutungen. Zur Prophylaxe von Thrombembolien bei Vorhofflimmern empfiehlt die European Society of Cardiology in ihrer Leitlinie von 2016 deshalb, die NOAK gegenüber VKA zu bevorzugen (Empfehlungsgrad I/Evidenzlevel A). Für Patienten mit mechanischem Klappenersatz und schwerer Niereninsuffizienz besteht jedoch weiterhin die Indikation zur Therapie mit VKA. Ebenso gilt dies für die Prophylaxe von venösen thrombembolischen Sekundärereignissen bei Tumorpatienten. Eine Therapie mit VKA ist also auch heute kein Kunstfehler, insbesondere wenn eine gute Einstellung der International Normalized Ratio erreicht wird, jedoch stellen die NOAK für viele Patienten eine sehr gute Alternative dar, um mit weniger Aufwand für Arzt und Patient eine mindestens ebenso gute Wirkung zu erzielen.

Abstract

Atrial fibrillation and venous thromboembolisms are frequent cardiovascular diseases. Until a few years ago only vitamin K antagonists (VKA) were available for oral anticoagulation as primary and secondary prevention of thrombembolic events. Currently, the non-vitamin K dependent new oral anticoagulants (NOAC) dabigatran, rivaroxaban, apixaban and edoxaban are approved for use. The approval studies, meta-analyses and data from registries provide evidence for the superiority of NOAC vs. VKA with respect to reduction of thrombembolisms and reduced bleeding complications; therefore, in the 2016 European Society of Cardiology (ESC) guidelines the use of NOAC is recommended as first line therapy for anticoagulation in atrial fibrillation (recommendation grade I/evidence level A). In patients with mechanical heart valve replacement and severe renal dysfunction VKA are still clearly indicated. This also holds true for prophylaxis of secondary thromboembolic events in tumor patients. Thus, even today therapy with VKA must not be regarded as medical malpractice, especially when a good adjustment of the international normalized ratio can be achieved; however, for many patients NOAC represent a very good alternative and lead to at least equal results with less effort for the prescribing physician and the patient.

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Authors and Affiliations

  1. 3. Medizinische Abteilung (Kardiologie, Pneumologie und Internistische Intensivmedizin), Asklepios Klinik Altona, Paul-Ehrlich-Str. 1, 22763, Hamburg, Deutschland

    E. Rafflenbeul &  J. Müller-Ehmsen

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  1. E. Rafflenbeul
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  2. J. Müller-Ehmsen
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Correspondence to E. Rafflenbeul or J. Müller-Ehmsen.

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Interessenkonflikt

Vortragshonorare für J. Müller-Ehmsen von Boehringer Ingelheim, Bayer, Pfizer/BMS und Daiichi Sankyo. E. Rafflenbeul gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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M. Wehling, Mannheim

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Rafflenbeul, E., Müller-Ehmsen, J. Vitamin-K-Antagonisten. Internist 58, 90–99 (2017). https://doi.org/10.1007/s00108-016-0168-x

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