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Hamostaseologie 2015; 35(04): 351-357
DOI: 10.5482/HAMO-14-12-0082
Review
Schattauer GmbH

Management of bleeding with oral anticoagulants in patients with atrial fibrillation

Blutungsmanagment mit oralen Antikoagulanzien bei Patienten mit Vorhofflimmern
J. Bosch
1   Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
,
J. W. Eikelboom
1   Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
› Author Affiliations
Further Information

Publication History

received: 15 December 2014

accepted in revised form: 04 May 2015

Publication Date:
28 December 2017 (online)

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Summary

Fear of bleeding is a common barrier to the use of anticoagulants. Warfarin has been the only oral anticoagulant for more than 60 years and warfarin-related bleeding is reported to be the most common drug-related cause of emergency hospitalization in elderly Americans. Non-vitamin K oral antagonists were introduced five years ago and compared with warfarin are associated with lower risk of intracranial bleeding, and similar or lower case fatality after major bleeding. Despite their superior safety profile, serious bleeding can occur. Most bleeding can be managed with holding the drug, local measures to control the bleeding and transfusion support as required because the NOACs have a relatively short half life and their anticoagulant effect rapidly dissipates. In patients with ongoing bleeding despite supportive measures and in those with lifethreatening bleeding, consideration may be given to the use of general hemostatic agents. Experimental and animal evidence suggests that 3 and 4 factor prothrombin complex concentrates can improve hemostasis in the presence of a NOAC and this is reinforced by anecdotal evidence in humans. Specific antidotes are currently in phase 3 trials and could become available in the near future.

Angst vor Blutungen ist ein häufiges Hindernis für die Einnahme von Antikoagulanzien. Warfarin war über 60 Jahre der einzige orale Gerinnungshemmer; Blutungen unter Warfarin waren bei älteren Amerikanern die häufigste arzneimittelbedingte Ursache für eine stationäre Notfallaufnahme. Neue (Nicht-Vitamin K) orale Antikoagulanzien wurden vor 5 Jahren eingeführt; im Vergleich zu Warfarin sind sie mit einem geringeren Risiko für intrakranielle Blutungen und vergleichbaren oder niedrigeren Todesfallraten nach größeren Blutungen verbunden. Trotz ihres überlegenen Sicherheitsprofils können schwerwiegende Blutungen auftreten. Die meisten Blutungen können durch Absetzen des Medikaments, lokale Maßnahmen zur Blutungskontrolle und ggfs. Transfusion behandelt werden, da NOAK eine relativ kurze Halbwertszeit besitzen und ihre gerinnungshemmende Wirkung rasch nachlässt. Bei Patienten mit anhaltenden Blutungen trotz unterstützender Maßnahmen und bei lebensbedrohlichen Blutungen kommen allgemein hämostatische Arzneimittel in Betracht. Experimentelle Daten und Tierversuche lassen darauf schließen, dass 3 bis 4 Prothrombinkomplex-Konzentrate in Gegenwart eines NOAK positiv auf die Gerinnung wirken, was durch Einzelfallberichte bei Menschen untermauert wird. Spezifische Antidots befinden sich in Phase-IIIStudien und könnten in naher Zukunft zur Verfügung stehen.

Keywords

Bleeding - atrial fibrillation - anticoagulation

Schlüsselwörter

Blutung - Vorhofflimmern - Antikoagulation
 

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