Differenzialtherapie der direkten oralen Antikoagulanzien (DOAKs) – Welches Präparat in welcher Situation einsetzen?

Zusammenfassung

Die direkten oralen Antikoagulantien (DOAKs) sind eine neue Behandlungs-Alternative zu Vitamin-K-Antagonisten zur Prävention von Thromboembolien bei Patienten mit Vorhofflimmern und entsprechendem Risikoprofil. Gegenwärtig sind 3 Präparate für diese Indikation zugelassen und zwar Dabigatran, Rivaroxaban und Apixaban, die jeweils gegen Warfarin in unterschiedlichen Studien evaluiert wurden (RE-LY, ROCKET-AF und ARISTOTLE), bislang aber nicht direkt gegeneinander verglichen wurden. Aussagen bezüglich der Differenzialtherapie dieser DOAKs sind entsprechend nur indirekt möglich.

Summary

The direct oral anticoagulants (DOACs) are new treatment alternatives to vitamin K antagonists for prevention of thromboembolic events in patients with atrial fibrillation at risk. At present the three drugs Dabigatran, Rivaroxaban and Apixaban are approved for this indication and were compared to warfarin in different studies (RE-LY, ROCKET-AF und ARISTOTLE), but were never compared directly. Statements concerning the differential therapy of these DOACs can therefore be made only indirectly.

Key words

Atrial fibrillation - anticoagulation - direct oral anticoagulants - prevention of thromboembolic events - gastrointestinal bleeding - drug interactions

• Literatur

• 1 Connolly SJ, Ezekowitz MD, Yusuf S et al. RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-1151
• 2 Granger CB, Alexander JH, McMurray JJ et al. ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365: 981-992
• 3 Patel MR, Mahaffey KW, Garg J et al. ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365: 883-891
• 4 Miller CS, Grandi SM, Shimony A et al. Meta-analysis of efficacy and safety of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus warfarin in patients with atrial fibrillation. Am J Cardiol 2012; 110: 453-460
• 5 Ruff CT, Giugliano RP, Braunwald E et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383: 955-962
• 6 Hankey GJ, Patel MR, Stevens SR et al. ROCKET AF Steering Committee Investigators. Rivaroxaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of ROCKET AF. Lancet Neurol 2012; 11: 315-322
• 7 Easton JD, Lopes RD, Bahit MC et al. ARISTOTLE Committees and Investigators. Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial. Lancet Neurol 2012; 11: 503-511
• 8 Diener HC, Connolly SJ, Ezekowitz MD et al. RE-LY study group. Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurol 2010; 9: 1157-1163 Erratum in: Lancet Neurol 2011; 10: 27
• 9 Heidbuchel H, Verhamme P, Alings M, Antz M et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013; 15: 625-651
• 10 Camm AJ, Lip GY, De Caterina R et al. ESC Committee for Practice Guidelines-CPG; Document Reviewers. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation-developed with the special contribution of the European Heart Rhythm Association. Europace 2012; 14: 1385-1413
• 11 Southworth MR, Reichman ME, Unger EF. Dabigatran and postmarketing reports of bleeding. N Engl J Med 2013; 368: 1272-1274
• 12 Alexander JH, Lopes RD, Thomas L et al. Apixaban vs. warfarin with concomitant aspirin in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J 2014; 35: 224-232
• 13 Dans AL, Connolly SJ, Wallentin L et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) trial. Circulation 2013; 127: 634-640
• 14 Alexander JH, Lopes RD, James S et al. APPRAISE-2 Investigators. Apixaban with antiplatelet therapy after acute coronary syndrome. N Engl J Med 2011; 365: 699-708
• 15 Connolly SJ, Ezekowitz MD, Yusuf S et al. Randomized Evaluation of Long-Term Anticoagulation Therapy Investigators. Newly identified events in the RE-LY trial. N Engl J Med 2010; 363: 1875-1876