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Erschienen in: Medizinische Klinik - Intensivmedizin und Notfallmedizin 6/2021

31.08.2021 | Hämatologische Störungen in der Intensivmedizin | Leitthema

Management von Blutungen unter antithrombotischer Therapie

verfasst von: Dr. med. Georg Braun

Erschienen in: Medizinische Klinik - Intensivmedizin und Notfallmedizin | Ausgabe 6/2021

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Zusammenfassung

Hintergrund

Schwere Blutungen unter antithrombotischer Therapie sind im intensivmedizinischen Alltag häufig und herausfordernd, einerseits muss eine rasche Blutungskontrolle erreicht werden, andererseits müssen thromboembolische Komplikationen vermieden werden.

Ziel der Arbeit

In dem Leitthemenbeitrag wird eine kurze Übersicht über die direkten oralen Antikoagulanzien, therapeutische Optionen und konkrete Handlungsanweisungen gegeben.

Ergebnisse

Neben Allgemeinmaßnahmen bei mit direkten oralen Antikoagulanzien (DOAK-)assoziierten Majorblutungen stehen im Wesentlichen Prothrombinkonzentrate (PPSB) und Idarucizumab als Antidottherapie zur Verfügung. Bei Blutungen unter Heparinen steht als mögliches Antidot Protaminsulfat zur Verfügung.

Schlussfolgerung

Insbesondere zum Stellenwert von Andexanet alfa in der Therapie von Faktor-Xa-Inhibitor-assoziierten Blutungen sind weitere Studien erforderlich.
Literatur
1.
2.
Zurück zum Zitat Guelker JE et al (2019) Increasing use of anticoagulants in Germany and its impact on hospitalization for gastrointestinal bleeding. Thromb Res 181:135–140 CrossRef Guelker JE et al (2019) Increasing use of anticoagulants in Germany and its impact on hospitalization for gastrointestinal bleeding. Thromb Res 181:135–140 CrossRef
3.
Zurück zum Zitat Schulman S et al (2005) Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 3(4):692–694 CrossRef Schulman S et al (2005) Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 3(4):692–694 CrossRef
4.
Zurück zum Zitat Tomaselli GF et al (2020) 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: a report of the American College of Cardiology Solution Set Oversight committee. J Am Coll Cardiol 76(5):594–622 CrossRef Tomaselli GF et al (2020) 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: a report of the American College of Cardiology Solution Set Oversight committee. J Am Coll Cardiol 76(5):594–622 CrossRef
5.
Zurück zum Zitat Padrini R (2019) Clinical pharmacokinetics and pharmacodynamics of direct oral anticoagulants in patients with renal failure. Eur J Drug Metab Pharmacokinet 44(1):1–12 CrossRef Padrini R (2019) Clinical pharmacokinetics and pharmacodynamics of direct oral anticoagulants in patients with renal failure. Eur J Drug Metab Pharmacokinet 44(1):1–12 CrossRef
6.
Zurück zum Zitat Douxfils J et al (2018) Laboratory testing in patients treated with direct oral anticoagulants: a practical guide for clinicians. J Thromb Haemost 16(2):209–219 CrossRef Douxfils J et al (2018) Laboratory testing in patients treated with direct oral anticoagulants: a practical guide for clinicians. J Thromb Haemost 16(2):209–219 CrossRef
7.
Zurück zum Zitat Steffel J et al (2018) The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 39(16):1330–1393 CrossRef Steffel J et al (2018) The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 39(16):1330–1393 CrossRef
8.
Zurück zum Zitat Doherty JU et al (2017) 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology clinical expert consensus document task force. J Am Coll Cardiol 69(7):871–898 CrossRef Doherty JU et al (2017) 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology clinical expert consensus document task force. J Am Coll Cardiol 69(7):871–898 CrossRef
9.
Zurück zum Zitat Samuelson BT et al (2017) Laboratory assessment of the anticoagulant activity of direct oral anticoagulants: a systematic review. Chest 151(1):127–138 CrossRef Samuelson BT et al (2017) Laboratory assessment of the anticoagulant activity of direct oral anticoagulants: a systematic review. Chest 151(1):127–138 CrossRef
10.
Zurück zum Zitat Burnett AE et al (2016) Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis 41(1):206–232 CrossRef Burnett AE et al (2016) Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis 41(1):206–232 CrossRef
11.
Zurück zum Zitat Levy JH et al (2016) When and how to use antidotes for the reversal of direct oral anticoagulants: guidance from the SSC of the ISTH. J Thromb Haemost 14(3):623–627 CrossRef Levy JH et al (2016) When and how to use antidotes for the reversal of direct oral anticoagulants: guidance from the SSC of the ISTH. J Thromb Haemost 14(3):623–627 CrossRef
12.
Zurück zum Zitat Babin JL, Traylor KL, Witt DM (2017) Laboratory monitoring of low-molecular-weight heparin and fondaparinux. Semin Thromb Hemost 43(3):261–269 PubMed Babin JL, Traylor KL, Witt DM (2017) Laboratory monitoring of low-molecular-weight heparin and fondaparinux. Semin Thromb Hemost 43(3):261–269 PubMed
13.
Zurück zum Zitat Connolly SJ et al (2019) Full study report of andexanet alfa for bleeding associated with factor Xa inhibitors. N Engl J Med 380(14):1326–1335 CrossRef Connolly SJ et al (2019) Full study report of andexanet alfa for bleeding associated with factor Xa inhibitors. N Engl J Med 380(14):1326–1335 CrossRef
14.
Zurück zum Zitat Pollack CV Jr. et al (2017) Idarucizumab for Dabigatran reversal—Full cohort analysis. N Engl J Med 377(5):431–441 CrossRef Pollack CV Jr. et al (2017) Idarucizumab for Dabigatran reversal—Full cohort analysis. N Engl J Med 377(5):431–441 CrossRef
15.
Zurück zum Zitat Khorsand N et al (2016) Assessment of effectiveness of major bleeding management: proposed definitions for effective hemostasis: communication from the SSC of the ISTH. J Thromb Haemost 14(1):211–214 CrossRef Khorsand N et al (2016) Assessment of effectiveness of major bleeding management: proposed definitions for effective hemostasis: communication from the SSC of the ISTH. J Thromb Haemost 14(1):211–214 CrossRef
16.
Zurück zum Zitat Schwebach AA, Waybright RA, Johnson TJ (2019) Fixed-dose four-factor prothrombin complex concentrate for vitamin K antagonist reversal: does one dose fit all? Pharmacotherapy 39(5):599–608 CrossRef Schwebach AA, Waybright RA, Johnson TJ (2019) Fixed-dose four-factor prothrombin complex concentrate for vitamin K antagonist reversal: does one dose fit all? Pharmacotherapy 39(5):599–608 CrossRef
17.
Zurück zum Zitat Chai-Adisaksopha C et al (2016) Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal. A systematic review and meta-analysis. Thromb Haemost 116(5):879–890 CrossRef Chai-Adisaksopha C et al (2016) Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal. A systematic review and meta-analysis. Thromb Haemost 116(5):879–890 CrossRef
18.
Zurück zum Zitat Maguire M et al (2019) Thromboembolic risk of 4‑factor prothrombin complex concentrate versus fresh frozen plasma for urgent warfarin reversal in the emergency department. West J Emerg Med 20(4):619–625 CrossRef Maguire M et al (2019) Thromboembolic risk of 4‑factor prothrombin complex concentrate versus fresh frozen plasma for urgent warfarin reversal in the emergency department. West J Emerg Med 20(4):619–625 CrossRef
19.
Zurück zum Zitat Lipari L et al (2020) Emergent reversal of oral factor Xa inhibitors with four-factor prothrombin complex concentrate. Am J Emerg Med 38(12):2641–2645 CrossRef Lipari L et al (2020) Emergent reversal of oral factor Xa inhibitors with four-factor prothrombin complex concentrate. Am J Emerg Med 38(12):2641–2645 CrossRef
20.
Zurück zum Zitat Piran S et al (2019) Management of direct factor Xa inhibitor-related major bleeding with prothrombin complex concentrate: a meta-analysis. Blood Adv 3(2):158–167 CrossRef Piran S et al (2019) Management of direct factor Xa inhibitor-related major bleeding with prothrombin complex concentrate: a meta-analysis. Blood Adv 3(2):158–167 CrossRef
21.
Zurück zum Zitat Kupper C et al (2019) Idarucizumab administration in emergency situations: the Munich Registry of Reversal of Pradaxa(R) in clinical routine (MR REPAIR). J Neurol 266(11):2807–2811 CrossRef Kupper C et al (2019) Idarucizumab administration in emergency situations: the Munich Registry of Reversal of Pradaxa(R) in clinical routine (MR REPAIR). J Neurol 266(11):2807–2811 CrossRef
22.
Zurück zum Zitat Lu G et al (2020) A phase 2 PK/PD study of andexanet alfa for reversal of rivaroxaban and edoxaban anticoagulation in healthy volunteers. Blood Adv 4(4):728–739 CrossRef Lu G et al (2020) A phase 2 PK/PD study of andexanet alfa for reversal of rivaroxaban and edoxaban anticoagulation in healthy volunteers. Blood Adv 4(4):728–739 CrossRef
23.
Zurück zum Zitat Brown CS et al (2020) Real-world utilization of andexanet alfa. Am J Emerg Med 38(4):810–814 CrossRef Brown CS et al (2020) Real-world utilization of andexanet alfa. Am J Emerg Med 38(4):810–814 CrossRef
24.
Zurück zum Zitat Ammar AA et al (2021) Andexanet alfa versus 4‑factor prothrombin complex concentrate for reversal of factor Xa inhibitors in Intracranial hemorrhage. Neurocrit Care 35:255–261 CrossRef Ammar AA et al (2021) Andexanet alfa versus 4‑factor prothrombin complex concentrate for reversal of factor Xa inhibitors in Intracranial hemorrhage. Neurocrit Care 35:255–261 CrossRef
25.
Zurück zum Zitat Barra ME et al (2020) Evaluation of andexanet alfa and four-factor prothrombin complex concentrate (4F-PCC) for reversal of rivaroxaban- and apixaban-associated intracranial hemorrhages. J Thromb Haemost 18(7):1637–1647 CrossRef Barra ME et al (2020) Evaluation of andexanet alfa and four-factor prothrombin complex concentrate (4F-PCC) for reversal of rivaroxaban- and apixaban-associated intracranial hemorrhages. J Thromb Haemost 18(7):1637–1647 CrossRef
26.
Zurück zum Zitat CRASH‑3 Trial Collaborators (2019) Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet 394(10210):1713–1723 CrossRef CRASH‑3 Trial Collaborators (2019) Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet 394(10210):1713–1723 CrossRef
27.
Zurück zum Zitat HALT-IT Trial Collaborators (2020) Effects of a high-dose 24‑h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 395(10241):1927–1936 CrossRef HALT-IT Trial Collaborators (2020) Effects of a high-dose 24‑h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 395(10241):1927–1936 CrossRef
28.
Zurück zum Zitat Kuramatsu JB, Sembill JA, Huttner HB (2019) Reversal of oral anticoagulation in patients with acute intracerebral hemorrhage. Crit Care 23(1):206 CrossRef Kuramatsu JB, Sembill JA, Huttner HB (2019) Reversal of oral anticoagulation in patients with acute intracerebral hemorrhage. Crit Care 23(1):206 CrossRef
29.
Zurück zum Zitat Moia M, Squizzato A (2019) Reversal agents for oral anticoagulant-associated major or life-threatening bleeding. Intern Emerg Med 14(8):1233–1239 CrossRef Moia M, Squizzato A (2019) Reversal agents for oral anticoagulant-associated major or life-threatening bleeding. Intern Emerg Med 14(8):1233–1239 CrossRef
30.
Zurück zum Zitat Hassan K et al (2019) Cytosorb adsorption during emergency cardiac operations in patients at high risk of bleeding. Ann Thorac Surg 108(1):45–51 CrossRef Hassan K et al (2019) Cytosorb adsorption during emergency cardiac operations in patients at high risk of bleeding. Ann Thorac Surg 108(1):45–51 CrossRef
Metadaten
Titel
Management von Blutungen unter antithrombotischer Therapie
verfasst von
Dr. med. Georg Braun
Publikationsdatum
31.08.2021
Verlag
Springer Medizin
Erschienen in
Medizinische Klinik - Intensivmedizin und Notfallmedizin / Ausgabe 6/2021
Print ISSN: 2193-6218
Elektronische ISSN: 2193-6226
DOI
https://doi.org/10.1007/s00063-021-00848-7