Heparine – DOAKs – VKA

Zusammenfassung

Bei Tumorpatienten bestehen ein erhöhtes Thromboembolierisiko und nicht selten gleichzeitig ein erhöhtes Blutungsrisiko. Dies macht die Antikoagulation nicht ganz einfach. Es muss stets eine individuelle Nutzen-Risiko-Abwägung erfolgen. Stationäre Tumorpatienten erhalten in der Regel eine medikamentöse VTE-Prophylaxe meist mit einem niedermolekularen Heparin (NMH) in der Hochrisikoprophylaxedosierung. Bei ambulanten Tumorpatienten ist das VTE-Risiko deutlich geringer, sie erhalten nur dann eine medikamentöse Prophylaxe, wenn zusätzliche prothrombogene Risikofaktoren vorliegen. Tumorpatienten mit akuter VTE werden mindesten 3–6 Monate mit NMH in therapeutischer (gewichtsadaptierter) Dosis behandelt, erst danach kann man ggf. auf Vitamin-K-Antagonisten umsetzen. Neben den etablierten Antikoagulanzien wie Heparinen, Vitamin-K-Antagonisten, Fondaparinux sind in den letzten Jahren die direkten oralen Antikoagulantien (DOAKs) hinzugekommen. Die Zulassung der DOAKs erstreckt sich aktuell auf die Thromboembolieprophylaxe nach elektiver Hüft- und Knietotalendoprothese, der Schlaganfallprophylaxe bei nicht-valvulärem Vorhofflimmern und der Initial- und Folgetherapie nach tiefer Beinvenenthrombose und Lungenembolie. In den Phase-III-Studien waren ca. 4–10 % Tumorpatienten integriert. Die DOAKs haben hierbei gezeigt, dass sie mindestens gleichwertig sind im Vergleich zur Standardtherapie bezüglich Rezidiv-VTE bei vergleichbarer Blutungsrate. Dies ist ermutigend. Die Datenlage reicht aktuell jedoch noch nicht aus, um sie bei Tumorpatienten einzusetzen. Entsprechende Studien speziell für Tumorpatienten stehen noch aus.

Summary

Patients with cancer are at increased risk of venous thromboembolism (VTE). At the same time they have often an underlying bleeding risk. That can often make decisions surrounding the administration of anticoagulants complicate. Individual risk-benefit calculation is necessary. During hospital stage the patients get, if there are no contraindications, a medical VTE prophylaxis with low molecular weight heparin (LMWH). Whereas outpatients don`t get a prophylaxis because they are at low risk of thromboembolism. If additional risk factor for VTE exists a decision for medical VTE prophylaxis should be taken into account. In patients with cancer and acute VTE, LMWH is recommended as treatment of choice for initial and long-term management in a body weight adapted dosage. After a period of 3–6 months and if a prolonged treatment is necessary, guidelines allow to switch from LMWH to VKA for further anticoagulant therapy. Beside the established anticoagulants like heparin, vitamin K antagonists, fondaparinux new oral direct anticoagulants (DOACs) were established in the last years. These substances are evaluated in in clinical trials. They are approved for treatment of acute VTE, for secondary prophylaxis and for prevention of ischemic stroke in patients with arterial fibrillation. In the VTE trials, 4–10 % of the enrolled patients had a history of cancer. The data shows that DOACs can prevent recurrent VTE as good as standard therapy with enoxaparin/warfarin without more bleeding complications. The results are encouraging. Because of the limited data the direct oral anticoagulants are not recommended for treatment of VTE at this time. Further studies are necessary.

English version available at www.phlebologieonline.de

Schlüsselwörter

Antikoagulation - Tumor - niedermolekulare Heparine - DOAKs

Keywords

Anticoagulation - cancer - LMWH - DOACs

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