Blutungsmanagement bei DOAK – Stellenwert der Antidote

Abstract

The directly acting oral anticoagulants (DOAC), i. e. inhibitors of factor Xa (apixaban, edoxaban and rivaroxaban) have gained increasing importance in the treatment and prophylaxis of thromboembolic events. However, concerns have been raised about the possible bleeding complications and the lack of antidots compared to the established vitamin k antagonists. Regarding bleeding complications, recent data indicate a comparable to decreased incidence of bleeding events in DOAC when compared to vitamin k antagonists. An antidote for dabigatran is already available, antidotes for the other substances are currently under development and investigation. We propose an individualized concept regarding the diagnosis and treatment of DOAC-related bleeding event based on the local infrastructure and patient collective. General measures including circulatory stabilization, volume resuscitation, allogeneic transfusion and substitution of coagulation factors are the basis of bleeding treatment. Specific aims including the use of antidotes are especially important in moderate to severe bleeding complications.

Kernaussagen

• Die Inzidenz von Blutungen unter DOAK ist vergleichbar bis geringer als bei Vitamin-K-Antagonisten.

• Für Dabigatran ist ein spezifisches Antidot verfügbar, für die weiteren Substanzen aus der Gruppe der DOAK sind Antidots in der Entwicklung bzw. klinischen Untersuchung.

• Laborchemische Verfahren können helfen, die Plasmakonzentration des jeweiligen DOAK abzuschätzen.

• Für Blutungsnotfälle sollte ein Konzept, basierend auf dem behandelten Patientenkollektiv sowie den lokalen Gegebenheiten vorgehalten werden.

• Bei Blutungskomplikation sind Basismaßnahmen zur Blutungskontrolle essenziell.

• Der Einsatz von PPSB mit 30 – 50 IE/kgKG sollte bei moderaten bis schweren Blutungskomplikationen erwogen werden.

• Der Einsatz des spezifischen Antagonisten von Dabigatran sollte bei schweren Blutungen unter Dabigatran erwogen werden.

• Literatur

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