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Der Klinikarzt 2018; 47(04): 164-170
DOI: 10.1055/a-0593-3513
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© Georg Thieme Verlag Stuttgart · New York

Gerinnungshemmende Therapie

Haben die direkten oralen Antikoagulanzien die Vitamin-K-Antagonisten „verbessert“?
Carl-Erik Dempfle
IMD Gerinnungszentrum Mannheim, Mannheim
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Publication History

Publication Date:
09 May 2018 (online)

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Zusammenfassung

Eine gerinnungshemmende Therapie mit Vitamin-K-Antagonisten erfordert eine individuelle Dosisfindung und eine ständige Therapiekontrolle.

Die Wirkdauer insbesondere von Phenprocoumon ist mit bis zu 21 Tagen sehr lang und nicht vorhersehbar und verkürzt sich nach Vitamin-K-Gabe auf 2 Tage, es besteht ein erhebliches Blutungsrisiko und der Schweregrad der Blutungen ist in der Regel höher als bei vergleichbaren Blutungen unter direkten oralen Antikoagulanzien (DOAK). Für operative Eingriffe müssen Vitamin-K-Antagonisten meist abgesetzt werden, die Empfehlungen einer präoperativen 5-tägigen Therapiepause ohne Überbrückung durch ein niedermolekulares Heparin für Warfarin sind auf Phenprocoumon nicht übertragbar. Bei Absetzen von DOAK wird eine normale Hämostasefunktion hingegen in der Regel innerhalb von 24–48 Stunden erreicht. Längerfristige Behandlung mit Vitamin-K-Antagonisten führt häufig zu Osteoporose und vermehrter Atherosklerose, sowie zu zunehmender Beeinträchtigung der Nierenfunktion, Effekte, die unter DOAK nicht beobachtet werden.

Spezielle Probleme für Vitamin K-Antagonisten ergeben sich bei Patienten mit Antiphospholipid-Syndrom, Protein C-Mangel, Protein S-Mangel oder Faktor VII-Mangel. Für eine bevorzugte Verwendung von DOAK sprechen rascher Wirkbeginn, kurze und vorhersehbare Wirkdauer bei standardisierter Dosierung, weniger und weniger schwere Blutungen, wesentlich einfacheres perioperatives Management und Vermeidung von Osteoporose und anderen Folgen der Vitamin-K-Antagonisten. Für die zugelassenen Indikationen haben DOAK daher etliche Vorteile im Vergleich zu den Vitamin-K-Antagonisten. Es ist aber zu berücksichtigen, dass auch bei Verwendung von DOAK eine gewissenhafte ärztliche Patientenführung nötig ist und die DOAK für einige Indikationen nicht zugelassen sind.

 

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