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Zeitschrift für Gerontologie und Geriatrie

, Volume 49, Issue 3, pp 216–226 | Cite as

Neue orale Antikoagulanzien zur Prophylaxe von Schlaganfällen

Ergebnis einer Expertenkonferenz zum praktischen Einsatz bei geriatrischen Patienten
  • Philipp BahrmannEmail author
  • Fred Harms
  • Christian Martin Schambeck
  • Martin Wehling
  • Jürgen Flohr
Übersichten

Zusammenfassung

Geriatrische Patienten mit nichtvalvulärem Vorhofflimmern (VHF) erhalten zunehmend neue orale Antikoagulanzien (NOAK) zur Schlaganfallprophylaxe. Das vorliegende Manuskript berichtet die Ergebnisse einer Expertenrunde zum praktischen Einsatz der NOAK bei geriatrischen Patienten. Eine interdisziplinäre Expertengruppe diskutierte die aktuelle Situation der Schlaganfallprävention bei geriatrischen Patienten und ihr praktisches Management in der täglichen klinischen Praxis. Das Thema wurde durch gezielte Impulsreferate und kritische Analyse als Grundlage für den Expertenkonsens diskutiert. Die wichtigsten Aspekte sind in diesem Beitrag zusammengefasst.In der VHF-Leitlinie der „European Society of Cardiology“ (ESC) werden für die Antikoagulation bei Patienten mit nichtvalvulärem VHF NOAK bevorzugt und Vitamin-K-Antagonisten (VKA) als Alternative empfohlen. Momentan finden die Faktor-Xa-Inhibitoren Apixaban und Rivaroxaban und der Thrombininhibitor Dabigatran als NOAK bei VHF klinische Anwendung. Für diese Medikamente bestehen viele Gemeinsamkeiten, für die differenzierte Pharmakotherapie aber auch wichtige Unterschiede. Die NOAK haben bei geriatrischen Patienten eine Reihe von Vorteilen gegenüber den VKA, vorrangig durch das bessere Nutzen-Risiko-Verhältnis aufgrund einer verminderten Zahl von Blutungsereignissen, und ein insgesamt geringeres Risiko für Arzneimittelinteraktionen. Hervorzuheben ist auch die einfachere Handhabung der NOAK im Alltag (kein INR-Monitoring erforderlich und unkompliziertere Unterbrechungen der Therapie bei geplanten Interventionen). Für geriatrische Patienten sollten vorzugsweise NOAK gewählt werden, die auch bei reduzierter Nierenfunktion eingesetzt werden können. Spiegelbestimmungen der NOAK werden zwar noch nicht flächendeckend angeboten, sind jedoch nicht mehr teuer und sollten bei Erfordernis (z. B. Adhärenzkontrolle bei Demenz) auch durch den niedergelassenen Arzt veranlasst werden. Eine regelmäßige Überprüfung der Indikationsstellung der NOAK (wie auch aller anderen Medikamente des Patienten) ist unabdingbar. Insgesamt sollten NOAK den hierfür geeigneten Patienten nicht vorenthalten werden.

Schüsselwörter

Schlaganfall Prävention Adhärenz Ältere Patienten Interdisziplinäres Management 

New oral anticoagulants for prophylaxis of stroke

Results of an expert conference on practical use in geriatric patients

Abstract

Geriatric patients with non-valvular atrial fibrillation (AF) are increasingly being treated with novel oral anticoagulants (NOAC) to prevent ischemic stroke. This article highlights the outcome of an expert meeting on the practical use of NOAC in elderly patients. An interdisciplinary group of experts discussed the current situation of stroke prevention in geriatric patients and its practical management in daily clinical practice. The topic was examined through focused impulse presentations and critical analyses as the basis for the expert consensus. The key issues are summarized in this paper. The European Society of Cardiology (ESC) guidelines from 2012 for the management of patients with non-valvular AF recommend NOAC as the preferred treatment and vitamin K antagonists (VKA) only as an alternative option. Currently, the NOAC factor Xa inhibitors apixaban and rivaroxaban and the thrombin inhibitor dabigatran are more commonly used in clinical practice for patients with AF. Although these drugs have many similarities and are often grouped together it is important to recognize that the pharmacology and dose regimes differ between compounds. Especially n elderly patients NOAC drugs have some advantages compared to VKA, e.g. less drug-drug interactions with concomitant medication and a more favorable risk-benefit ratio mostly driven by the reduction of bleeding. Treatment of anticoagulation in geriatric patients requires weighing the serious risk of stroke against an equally high risk of major bleeding and pharmacoeconomic considerations. Geriatric patients in particular have the greatest benefit from NOAC, which can also be administered in cases of reduced renal function. Regular control of the indications is indispensable, as also for all other medications of the patient. The use of NOAC should certainly not be withheld from geriatric patients who have a clear need for oral anticoagulation.

Keywords

Stroke Prevention Adherence Older Patients Interdisciplinary management 

Notes

Danksagungen

C. Azadi, Pfizer Pharma GmbH, Berlin, organisierte die Konferenz. Pfizer Pharma GmbH finanzierte die Konferenz und bot Unterstützung bei der Vorbereitung dieses Arbeitspapiers durch 3P Consulting, Seefeld, nahm jedoch keinen Einfluss auf die Inhalte. Alle Verfasser waren für kritische Überprüfungen des Manuskripts und für die Formulierung der zentralen Inhalte verantwortlich. Sie genehmigten die Endfassung des Manuskripts.

Einhaltung ethischer Richtlinien

Interessenkonflikt

P. Bahrman war Stipendiat des Forschungskollegs Geriatrie der Robert Bosch Stiftung, Stuttgart. Er erhielt Vortrags- und Beratungshonorare von Pfizer, Bayer, Novartis, AstraZeneca, Boehringer-Ingelheim und ThermoScientific. J. Flohr erhielt Beratungs- und Vortragshonorare von Berlin-Chemie, Grünenthal, GSK, Hexal, Mundipharma, MSD, Pohl-Boskamp, Shire, UCB und Pfizer. M. Wehling war von 2004 bis 2006 während seines Sabbaticals von seiner Professur an der Universität Heidelberg bei AstraZeneca R&D, Mölndal, als Leiter der medizinischen Forschung (translationale Medizin) beschäftigt. Nach Rückkehr auf seine Position im Januar 2007 erhielt er Vortrags- und Beratungshonorare von Sanofi-Aventis, Novartis, Takeda, Roche, Pfizer, Bristol-Myers Squibb, Bayer, Boehringer-Ingelheim, Otsuka, Daichii-Sankyo, Lilly, LEO, Shire und Novo-Nordisk. F. Harms und C.M. Schambeck geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Philipp Bahrmann
    • 1
    Email author
  • Fred Harms
    • 2
  • Christian Martin Schambeck
    • 3
  • Martin Wehling
    • 4
  • Jürgen Flohr
    • 5
  1. 1.Institut für Biomedizin des AlternsFriedrich-Alexander-Universität Erlangen-NürnbergNürnbergDeutschland
  2. 2.European Health Care FoundationZugSchweiz
  3. 3.HämostatikumMünchenDeutschland
  4. 4.Institut für Experimentelle und Klinische Pharmakologie und Toxikologie, Medizinische Fakultät MannheimRuprecht-Karls-UniversitätHeidelbergDeutschland
  5. 5.Allgemeinmedizinische GemeinschaftspraxisLeipzigDeutschland

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