Skip to main content
SpringerLink
Log in

Gastrointestinale Nebenwirkungen von Antikoagulanzien

Gastrointestinal side effects due to anticoagulants

  • Schwerpunkt: Medikamentöse Nebenwirkungen im Gastrointestinaltrakt
  • Published:
Der Gastroenterologe Aims and scope

Zusammenfassung

Blutungen gehören nicht nur zu den häufigsten, sondern auch zu den potenziell lebensbedrohlichen Komplikationen einer Therapie mit Antikoagulanzien. Wesentlich beeinflusst wird das Risiko durch die Nebenerkrankungen des Patienten und die Begleitmedikation. Bereits durch Blutung klinisch manifest gewordene Ulzera im Gastrointestinaltrakt besitzen ein hohes Rezidivrisiko unter Antikoagulation. Etablierte Scoresysteme bieten eine Möglichkeit, das generelle Blutungsrisiko abzuschätzen.

Bei Verwendung von unfraktioniertem Heparin ist die kontinuierliche i.v.-Therapie der i.v.-Bolusgabe hinsichtlich der Blutungsrate überlegen, niedermolekulare Heparine wiederum sind vergleichbar sicher bei noch niedrigerer Rate an Blutungskomplikationen.

Typischerweise findet sich im endoskopischen Bild neben den üblichen Pathologien häufiger keine lokalisierbare Blutungsquelle.

Zur Vermeidung derartiger Komplikationen sollte stets eine sorgfältige Indikationsstellung erfolgen, die Antikoagulation mit geringster Intensität gewählt und wenn immer möglich eine ambulante Selbstmessung angestrebt werden. Eine routinemäßige gastroskopische Kontrolle vor Beginn einer Antikoagulation ist nicht indiziert.

Abstract

Anticoagulation-related bleeding is by far the most common complication caused by these compounds. It is also potentially life-threatening. The patient’s comorbidities and comedication impact heavily on individual risk. A history of gastrointestinal bleeding due to ulceration predisposes to recurrent bleeding. Risk of bleeding can be estimated using established scoring systems.

Continuous i.v. heparin infusion is superior to i.v. bolus application in terms of bleeding complication rates, whereas low-molecular-weight-heparins are as effective and even more advantageous in terms of such complications.

Typically, endoscopy reveals the usual pathologies with no identifiable bleeding source.

In order to avoid such a complication, indications for anticoagulation therapy should be carefully selected, the lowest possible level of anticoagulation chosen and, whenever possible, self-monitoring should be recommended. A routine gastroscopy before starting anticoagulant therapy is not indicated.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Amann B, Tinzmann I, Unckell J et al. (2006) Gastroskopie vor oraler Antikoagulation – Prävalenz blutungsrelevanter Befunde im Gastrointestinaltrakt bei asymptomatischen Patienten. Poster 266; GTH Basel 2006

  2. Anand SS, Yusuf S, Pogue J et al. (2003) Relationship of activated partial thromboplastin time to coronary events and bleeding in patients with acute coronary syndromes who receive heparin. Circulation 107: 2884–2888

    Article  PubMed  Google Scholar 

  3. Ansell J, Holden A, Knapic N (1989) Patient self-management of oral anticoagulation guided by capillary (fingerstick) whole blood prothrombin times. Arch Intern Med 149: 2509–2511

    Article  PubMed  Google Scholar 

  4. Atrial Fibrillation Investigators (1996) Bleeding during antithrombotic therapy in patients with atrial fibrillation. Arch Intern Med 156: 409–416

    Article  PubMed  Google Scholar 

  5. Battistella M, Mamdami MM, Juurlink DN, Laupacis A (2005) Risk of upper gastrointestinal hemorrhage in warfarin users treated with nonselective NSAIDs or COX-2 inhibitors. Arch Intern Med 165: 189–192

    Article  PubMed  Google Scholar 

  6. Bentley PG, Kakkar VV, Scully MF (1980) An objective study of alternative methods of heparin administration. Thromb Res 18: 177–187

    Article  PubMed  Google Scholar 

  7. Beyth RJ, Quinn LM, Landefeld CS (1998) Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin. Am J Med 105: 91–99

    Article  PubMed  Google Scholar 

  8. Campbell NR, Hull RD, Brant R et al. (1996) Aging and heparin-related bleeding. Arch Intern Med 156: 857–860

    Article  PubMed  Google Scholar 

  9. Coumadin-Aspirin Reinfarction Study (CARS) Investigators (1997) Randomised double-blind trial of fixed low-dose warfarin with aspirin after myocardial infarction. Coumadin-Aspirin Reinfarction Study (CARS) Investigators. Lancet 350: 389–396

    Article  PubMed  Google Scholar 

  10. Casais P, Luceros AS, Meschengieser S et al. (2000) Bleeding risk factors in chronic oral anticoagulation with acenocoumarol. Am J Hematol 2000; 63(4): 192–196

    Google Scholar 

  11. Coon WW, Willis PW (1974) Hemorrhagic complications of anticoagulant therapy. Arch Intern Med 133: 386–392

    Article  PubMed  Google Scholar 

  12. Couturaud F, Julian JA, Kearon C (2001) Low molecular weight heparin administered once versus twice daily in patients with venous thromboembolism: a meta-analysis. Thromb Haemost 86: 980–984

    PubMed  Google Scholar 

  13. Cropp JS, Bussey HI (1997) A review of enzyme induction of warfarin metabolism with recommendations for patient management. Pharmacotherapy 17: 917–928

    PubMed  Google Scholar 

  14. EPILOG Investigators (eds) (1997) Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. The EPILOG Investigators. N Engl J Med 336: 1689–1696

    Article  PubMed  Google Scholar 

  15. European Atrial Fibrillation Trial (EAFT) Study Group (1995) Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia. N Engl J Med 333: 5–10

    Article  PubMed  Google Scholar 

  16. Executive Steering Committee on behalf of the SPORTIF III Investigators (2003) Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomized controlled trial. Lancet 362: 1691–1698

    Article  PubMed  Google Scholar 

  17. Fihn SD, McDonell M, Martin D et al. (1993) Risk factors for complications of chronic anticoagulation: a multicenter study. Ann Intern Med 118: 511–520

    PubMed  Google Scholar 

  18. Furie B, Diuguid CF, Jacobs M et al. (1990) Randomized prospective trial comparing the native prothrombin antigen with the prothrombin time for monitoring oral anticoagulant therapy. Blood 75: 344–349

    PubMed  Google Scholar 

  19. Gould MK, Dembitzer AD, Doyle RL et al. (1999) Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A meta-analysis of randomized, controlled trials. Ann Intern Med 130: 800–809

    PubMed  Google Scholar 

  20. Greenblatt DJ, von Moltke LL (2005) Interaction of warfarin with drugs, natural substances, and foods. J Clin Pharmacol 45: 127–132

    Article  PubMed  Google Scholar 

  21. Halbritter K, Beyer J, Oettler W, Schellong S (2006) Register zur Erfassung von Komplikationen unter Vitamin-K-Antagonisten. Poster 267, GTH Basel 2006

  22. Hull RD, Raskob GE, Rosenbloom D et al. (1990) Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis. N Engl J Med 322: 1260–1264

    PubMed  Google Scholar 

  23. Iorio A, Guercini F, Pini M (2003) Low-molecular-weight heparin for the long-term treatment of symptomatic venous thromboembolism: meta-analysis of the randomized comparisons with oral anticoagulants. J Thromb Haemost 1: 1906–1913

    Article  PubMed  Google Scholar 

  24. Jacobs LG (2006) Warfarin pharmacology, clinical management, and evaluation of hemorrhagic risk for the elderly. Clin Geriatr Med 22: 17–32

    PubMed  Google Scholar 

  25. Jick H, Slone D, Borda IT, Shapiro S (1968) Efficacy and toxicity of heparin in relation to age and sex. N Engl J Med 279: 284–286

    PubMed  Google Scholar 

  26. Kucher N, Connolly S, Beckman JA et al. (2004) International normalized ratio increase before warfarin-associated hemorrhage: brief and subtle. Arch Intern Med 164(19): 2176–2179

    Article  PubMed  Google Scholar 

  27. Landefeld CS, Goldman L (1989) Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy. Am J Med 87: 144–152

    PubMed  Google Scholar 

  28. Landefeld CS, Anderson PA (1992) Guideline-based consultation to prevent anticoagulant-related bleeding. A randomized, controlled trial in a teaching hospital. Ann Intern Med 116: 829–837

    PubMed  Google Scholar 

  29. Landefeld CS, Beyth RJ (1993) Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention. Am J Med 95: 315–328

    Article  PubMed  Google Scholar 

  30. Landefeld CS, Flatley M, Weisberg M et al. (1987) Identification and preliminary validation of predictors of major bleeding in hospitalized patients starting anticoagulant therapy. Am J Med 82: 703–713

    Article  PubMed  Google Scholar 

  31. Le M, Hirsh J, Gent M et al. (1994) Double-blind randomized trial of very low dose warfarin for prevention of thromboembolism in stage IV breast cancer. Lancet 343: 886–889

    Article  PubMed  Google Scholar 

  32. Levine MN, Rascob G, Beyth RJ et al. (2004) Hemorrhagic complications of anticoagulant treatment. Chest 126: 287S–310S

    Article  PubMed  Google Scholar 

  33. Lim W, Dentali F, Eikelboom JW, Crowther MA (2006) Meta-Analysis: Low-molecular-weight heparin and bleeding in patients with severe renal insufficiency. Ann Intern Med 144: 673–684

    PubMed  Google Scholar 

  34. The Matisse Investigators (2003) The Matisse-DVT trial, a randomized double-blind study comparing once daily fondaparinux (Arista) with low molecular weight heparin (LWM) enoxaparin, twice daily, in the initial treatment of symptomatic deep vein thrombosis (DVT) (abstract). J Thromb Haemostasis 1 (Suppl 1): OC332

    Google Scholar 

  35. Petitti DB, Strom B, Melmon KL (1986) Duration of warfarin anticoagulation therapy and the probabilities of recurrent thromboembolism and hemorrhage. Am J Med 81: 255–259

    Article  PubMed  Google Scholar 

  36. Petitti DB, Strom BL, Melmon KL (1989) Prothrombin time ratio and other factors associated with bleeding in patients treated with warfarin. J Clin Epidemiol 42: 759–764

    Article  PubMed  Google Scholar 

  37. Peyman MA (1958) The significance of hemorrhage during the treatment of patients with the coumarin anticoagulants. Acta Med Scan 162: 1–62

    Google Scholar 

  38. Poli D, Antonucci E, Lombardi A et al. (2003) Low rate of bleeding and thrombotic complications of oral anticoagulant therapy independent of age in the real-practice of an anticoagulation clinic. Blood Coagul Fibrinolysis 14(3): 269–275

    Article  PubMed  Google Scholar 

  39. Pollard JW, Hamilton MJ, Christensen NA et al. (1962) Problems associated with long-term anticoagulant therapy. Circulation 25: 311–317

    PubMed  Google Scholar 

  40. Rubin TA, Murdoch M, Nelson DB (2003) Acute GI bleeding in the setting of supratherapeutic international normalized ratio in patients taking warfarin: endoscopic diagnosis, clinical management, and outcomes. Gastrointest Endosc 58: 369–372

    PubMed  Google Scholar 

  41. SPORTIF II Investigators (2003) Ximelagatran versus warfarin for stroke prevention in patients with non-valvular atrial fibrillation. J Am Coll Cardiol 41: 1445–1451

    Article  PubMed  Google Scholar 

  42. Thomopoulos KC, Mimidis KP, Theocharis GJ et al. (2005) Acute upper gastrointestinal bleeding in patients on long-term oral anticoagulation therapy: endoscopic findings, clinical management and outcome. World J Gastroenterol 11: 1365–1368

    PubMed  Google Scholar 

  43. Torn M, van der Meer FJ, Rosendaal FR (2004) Lowering the intensity of oral anticoagulant therapy: effects on the risk of hemorrhage and thromboembolism. Arch Intern Med 164(6): 668–673

    Article  PubMed  Google Scholar 

  44. White RH, McCurdy SA, von Marensdorff H et al. (1989) Home prothrombin time monitoring after the initiation of warfarin therapy. A randomized prospective study. Ann Intern Med 111: 730–737

    PubMed  Google Scholar 

  45. Wilson JR, Lampman J (1979) Heparin therapy: a randomized prospective study. Am Heart J 97: 155–158

    Article  PubMed  Google Scholar 

  46. Wilson JE, Bynum LJ, Parkey RW (1981) Heparin therapy in venous thromboembolism. Am J Med 70: 808–816

    Article  PubMed  Google Scholar 

  47. Yett HS, Skillman JJ, Salzman EW (1978) The hazards of heparin plus aspirin. N Engl J Med 298: 1092

    Google Scholar 

Download references

Interessenkonflikt

Keine Angaben

Author information

Authors and Affiliations

  1. Medizinische Klinik III Arbeitsbereich Angiologie, Universitätsklinik Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden

    K. M. Halbritter, S. Hochauf & S. M. Schellong

Authors
  1. K. M. Halbritter
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. Hochauf
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. M. Schellong
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to K. M. Halbritter.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Halbritter, K.M., Hochauf, S. & Schellong, S.M. Gastrointestinale Nebenwirkungen von Antikoagulanzien. Gastroenterologe 1, 180–187 (2006). https://doi.org/10.1007/s11377-006-0029-6

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11377-006-0029-6

Schlüsselwörter

Keywords

Search

Navigation