Résumé
Les services d’urgences sont de plus en plus confrontés à la gestion des hémorragies secondaires aux nouveaux anticoagulants oraux (NACOs), anti-IIa (dabigatran etexilate, Pradaxa®) ou anti-Xa (rivaroxaban, Xarelto®, apixaban, Eliquis®). De plus en plus prescrits dans certaines indications des antagonistes de la vitamine K (AVK) ou des héparines, à savoir la prévention des accidents cardioemboliques au cours de la fibrillation atriale non valvulaire et la prévention postopératoire et le traitement de la maladie thromboembolique veineuse, les NACOs induisent un risque d’hémorragie majeure ou cliniquement significative équivalent à celui des AVK. La fréquence d’hémorragie intracrânienne est réduite de moitié par rapport aux AVK, mais celle des hémorragies digestives est supérieure. En l’absence d’études cliniques dédiées et sur la base de données de pharmacologie en phases 1 et 2, le Groupe d’intérêt en hémostase périopératoire (GIHP) et le Groupe d’études sur l’hémostase et la thrombose (GEHT) ont émis des propositions selon le format des recommandations publiées en 2008 par la Haute Autorité de santé sur les AVK. Aux urgences du CHU de Toulouse a été mise en place une fiche réflexe diffusée à l’ensemble des praticiens susceptibles d’être confrontés à la prise en charge des hémorragies sous NACOs afin d’en assurer la meilleure gestion. La collaboration entre les spécialistes médicaux et chirurgicaux, réanimateurs, biologistes, la pharmacie et la pharmacovigilance permet à chaque établissement de renseigner les circonstances de ces accidents, leur prise en charge et d’inclure les données dans l’observatoire national GIHP-NACO pour assurer un large partage d’expérience sur des effectifs importants hors essais thérapeutiques.
Abstract
The management of major bleeding induced by the new oral anticoagulants (NOACs), anti-IIa (dabigatran Pradaxa ®) or anti-Xa (rivaroxaban Xarelto®, apixaban Eliquis®), is becoming a serious concern for emergency departments, as these drugs are prescribed in a growing proportion of patients for the prevention of stroke in non-valvular atrial fibrillation, the prevention of venous thrombosis in orthopedic surgery, or the treatment of venous thrombosis and pulmonary embolism. The incidence of major bleeding during the phase 3 clinical trials in these indications is not inferior to that of the comparators (vitamin K antagonists (VKAs) or heparins), with a significant reduction of intracranial hemorrhages, but an increase in gastrointestinal bleeding. The Groupe d’intérêt en hémostase périopératoire (GIHP), in collaboration with the French Group for Haemostasis and Thrombosis (GEHT), has published proposals for this management, mainly grounded on pharmacological data obtained during the early phases of drug development in target populations. These proposals are obviously of low evidence level, due to the lack of sufficient experience. After a brief presentation of the bleeding risk of the NACOs, these proposals and their rationale are described, and we report how, in our hospital, we promoted the collaboration between emergency staffs, medical and surgical clinicians, hematologists, pharmacists, and the pharmacovigilance system in order to improve this management. Very importantly, the consecutive cases are now prospectively included in a national observatory (GIHP-NACO) in order to provide a large number of bleeding reports on the real life conditions of use of these drugs.
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Momo-Boma, A., Barniol, C., Mémier, V. et al. Prise en charge par les services d’urgences des accidents hémorragiques graves chez les patients traités par les nouveaux anticoagulants oraux (NACOs). Ann. Fr. Med. Urgence 4, 173–180 (2014). https://doi.org/10.1007/s13341-014-0410-x
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DOI: https://doi.org/10.1007/s13341-014-0410-x