Nicht-Vitamin-K-abhängige orale Antikoagulanzien

Was ist in der Intensivmedizin zu beachten
Leitthema

Zusammenfassung

Nicht-Vitamin-K-abhängige orale Antikoagulanzien (NOAK) haben seit ihrer Einführung in die Therapie vor 7 Jahren bereits eine weite Verbreitung gefunden. Derzeit stehen 2 Gruppen von NOAK zur Verfügung, der Thrombinantagonist Dabigatran und die Faktor-Xa-Antagonisten Apixaban, Edoxaban und Rivaroxaban. Die Wahrscheinlichkeit nimmt stetig zu, dass mit NOAK behandelte Patienten auch in der Intensiv- und Notfallmedizin angetroffen werden.

Die Herausforderung besteht bei antikoagulierten Patienten zunächst darin, wie mit der Antikoagulation umgegangen wird. Bei der kurzen Halbwertszeit der NOAK reicht es in  der  Regel, das Nachlassen der Antikoagulanzienwirkung abzuwarten, bevor invasive oder operative Maßnahmen durchgeführt werden. In besonderen Fällen, in denen sofortige Handlung notwendig ist, kann die Wirkung der 3 Faktor-Xa-Antagonisten (und mit Einschränkung auch von Dabigatran) durch die Faktorenkonzentrate PPSB oder FEIBA aufgehoben werden oder unter Inkaufnahme eines erhöhten Blutungsrisikos sofort die Intervention durchgeführt werden. Dabigatran kann zusätzlich durch Idarucizumab, einem humanisierten Fab-Antikörperfragment, sicher antagonisiert werden. Idarucizumab ist daher zur Aufhebung der Antikoagulanzienwirkung von Dabigatran Mittel der Wahl.

Darüber hinaus können NOAK in begrenzten Indikationen auch als vorteilhafte Therapeutika in der Akut- und Notfallmedizin eingesetzt werden. Dies betrifft v. a. Patienten mit neu aufgetretener absoluter Tachyarrhythmie, die rasch kardiovertiert werden sollen, und Patienten mit akuter Lungenembolie. In der Regel wird heute aber die Akutphase immer noch mit einem parenteralen Heparin überbrückt und die Entscheidung für oder gegen ein NOAK auf einen Zeitpunkt nach der Stabilisierung der Patienten verschoben.

Schlüsselwörter

Blutgerinnung Blutung Faktor-Xa-Inhibitoren Dabigatran  Idarucizumab  

Non-vitamin K dependent oral anticoagulants

What is important in intensive care medicine

Abstract

Since first used in 2009, non-vitamin K oral anticoagulants (NOAC) have gained world-wide acceptance. Two groups of NOAC are currently used: the direct thrombin antagonist dabigatran and three direct factor  Xa antagonists apixaban, edoxaban, and ricaroxaban. With their increasing use for prevention of thromboembolism, the probability increases that NOAC-pretreated patients are admitted to emergency departments or intensive care units.

The clinical challenge in NOAC preanticoagulated patients is to adequately cope with the given anticoagulated status of such patients. Because of their short half-life, many patients will be adequately treated with a “wait and see” approach, and surgeries and interventions are postponed until anticoagulant activities have totally subsided. In the few cases where immediate action is mandated, based on appropriate risk assessments it can be decided either to take the increased hemorrhagic risk of early intervention or to transfuse factor concentrates like PPSB or FEIBA which can safely reverse the anticoagulant activities of the three factor Xa antagonists (and potentially also of dabigatran). Recently a humanized Fab antibody fragment for dabigatran, idarucizumab, has been introduced onto the market, that can immediately reverse the anticoagulant effects of dabigatran. For the reversal of dabigatran, idarucizumab is therefore the drug of choice.

In addition, in some specific indications of emergency and intensive care medicine, the primary use of a NOAC can be considered advantageous. Such indications are early cardioversion in patients admitted for new episodes of atrial fibrillation and patients with acute pulmonary embolism. For the widespread use of low-molecular-weight heparins in such indications, however, the decision to use a NOAC for anticoagulant therapy is frequently postponed to the treatment phase when the stabilized patient is already treated on the general ward.

Keywords

Blood coagulation Hemorrhage Factor Xa inhibitors Dabigatran Idarucizumab  

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Copyright information

© Springer Medizin Verlag Berlin 2016

Authors and Affiliations

  1. 1.St. Marien HospitalKlinik für Innere Medizin und Pneumologie, Katholisches Klinikum OberhausenOberhausenDeutschland

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