Empfehlungen zur Anwendung der indirekten und direkten Antikoagulanzien zur langfristigen Sekundärprophylaxe nach venösen Thromboembolien

Zusammenfassung

Die Dosierungen der direkten oralen Antikoagulanzien für die langfristige Erhaltungstherapie nach akuter tiefer Venenthrombose und Lungenembolie erfordern im Alltag häufig eine individuelle Entscheidung, da für die Präparate Apixaban und Rivaroxaban jeweils 2 Dosen zur Verfügung stehen, für die es keine festgelegten separaten Indikationsspektren gibt. Daher hat die Arbeitsgemeinschaft der niedergelassenen Gefäßchirurgen und Gefäßmediziner Deutschlands e. V. dieses Positionspapier entwickelt. Patienten mit einem klar identifizierbaren und passageren Triggerfaktor für die venöse Thromboembolie (z. B. Trauma, Operation, akute internistische Erkrankung, orale Kontrazeption, Schwangerschaft) oder einer isolierten Unterschenkelvenenthrombose haben ein geringes Rezidivrisiko und werden i. d. R. nicht dauerhaft antikoaguliert. Besteht eine hohes Rezidivrisiko bei fortbestehendem Triggerfaktor (z. B. fortbestehende aktive Tumorerkrankung, zweifelsfrei nachgewiesenes Antiphospholipidsyndrom sowie ein Gerinnungsinhibitormangel von Protein C, Protein S oder Antithrombin bei positiver Familienanamnese bez. venöser Thromboembolien [VTE], Erstereignis einer Lungenembolie, mehrfachen Rezidiven einer VTE) ist eine verlängerte Erhaltungstherapie indiziert, sofern nicht ein sehr hohes Blutungsrisiko dagegen spricht. Bei allen Patienten mit einer abgelaufenen VTE, bei denen man grundsätzlich die Antikoagulationsphase beenden würde, kann eine verlängerte Prophylaxe fortgeführt werden, da auch diese Patienten ein höheres Rezidivrisiko haben als ein Mensch, der noch nie eine VTE gehabt hat.

Abstract

In routine clinical work, the dosage of direct oral anticoagulants for long-term maintenance therapy after acute deep vein thrombosis and pulmonary embolism is often made on an individual basis. As two doses are available for the preparations apixaban and rivaroxaban and no separate indication spectra have been specified. The working group of practising vascular physicians and surgeons in Germany has therefore developed this position paper. Patients with a clearly identified and temporary trigger factor for venous thromboembolism (e.g. trauma, operation, acute internal disease, oral contraception or pregnancy or isolated thrombosis of veins in the lower leg have a lower risk of recurrence and are generally not given permanent anticoagulation. If there is a high risk of recurrence with unchanged trigger factor (e.g. active malignancy, unambiguous antiphospholipid syndrome or deficiency of a clotting factor, such as Protein C, Protein S or antithrombin with a positive family history of venous thromboembolism, first occurrence of a pulmonary embolism, multiple recurrence of VTE) prolonged maintenance therapy is indicated, unless this is contraindicated by a very high risk of bleeding. For all patients with former VTE and whose anticoagulation phase has in principle been completed, prolonged prophylaxis can be continued, as these patients too are at increased risk of VTE.

Schlüsselwörter

tiefe Venenthrombose - Lungenembolie - Antikoagulation - Langzeitprophylaxe

Key words

deep vein thrombosis - pulmonary embolism - anticoagulation - long-term prophylaxis

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