Einsatz von spezifischen Antidots bei DOAK-assoziierter schwerer gastrointestinaler Blutung – ein Expertenkonsensus

Valentin Fuhrmann; Jürgen Koscielny; Thomas Vasilakis; Tilo Andus; Adam Herber; Stefano Fusco; Elke Roeb; Ingolf Schiefke; Jonas Rosendahl; Matthias Dollinger; Karel Caca; Frank Tacke

doi:10.1055/a-2112-1834

Zeitschrift für Gastroenterologie, Table of Contents

Z Gastroenterol 2024; 62(05): 759-768
DOI: 10.1055/a-2112-1834

Übersicht

Einsatz von spezifischen Antidots bei DOAK-assoziierter schwerer gastrointestinaler Blutung – ein Expertenkonsensus

DOAK-Antagonisierung bei gastrointestinaler BlutungUse of specific antidotes in DOAC-associated severe gastrointestinal bleeding – an expert consensusAntagonozation of direct oral anticoagulants in gastrointestinal hemorrhages

Valentin Fuhrmann

¹Klinik für Allgemeine Innere Medizin und Gastroenterologie, Heilig Geist-Krankenhaus, Köln, Germany

²Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany

,

Jürgen Koscielny

³Gerinnungsambulanz mit Hämophiliezentrum, Charité Universitätsmedizin Berlin, Berlin, Germany (Ringgold ID: RIN14903)

,

Thomas Vasilakis

⁴Charité Universitätsmedizin Berlin, Department of Hepatology and Gastroenterology, Berlin, Germany

,

Tilo Andus

⁵Klinik für Allgemeine Innere Medizin, Gastroenterologie, Hepatologie und internistische Onkologie, Klinikum Stuttgart, Stuttgart, Germany

,

Adam Herber

⁶Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Leipzig, Germany (Ringgold ID: RIN39066)

,

Stefano Fusco

⁷Department of Gastroenterology, Eberhard-Karls-Universität Tübingen Medizinische Fakultät, Tübingen, Germany (Ringgold ID: RIN54188)

,

Elke Roeb

⁸Gastroenterology, Med. II, Gießen, Germany

,

Ingolf Schiefke

⁹Department of Gastroenterology and Hepatology, St. George Hospital, Leipzig, Germany

¹⁰Gastroenterologie und Hepatologie am Johannisplatz, Leipzig, Germany

,

Jonas Rosendahl

¹¹Clinic for Internal Medicine I, University Hospital Halle, Halle, Germany (Ringgold ID: RIN14942)

,

Matthias Dollinger

¹²Medizinische Klinik I Gastroenterologie, Nephrologie und Diabetologie, Klinikum Landshut gGmbH, Landshut, Germany (Ringgold ID: RIN39831)

¹³Innere Medizin I, University Hospital Ulm, Ulm, Germany (Ringgold ID: RIN27197)

,

Karel Caca

¹⁴Klinik für Innere Medizin, Gastroenterologie, Hämato-Onkologie, Diabetologie und Infektiologie, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany

,

Frank Tacke

⁴Charité Universitätsmedizin Berlin, Department of Hepatology and Gastroenterology, Berlin, Germany

› Author Affiliations

Abstract

Zusammenfassung

Gastrointestinale (GI) Blutungen gehören zu den häufigsten Komplikationen beim Einsatz direkt wirkender oraler Antikoagulanzien (DOAK). Für die Maßnahmen bei (vermuteter) GI-Blutung existieren klare (Notfall-)Algorithmen, bei denen im präendoskopischen Management die anamnestische Erfragung einer medikamentösen Antikoagulation und einfache Gerinnungstests erfolgen sollen. Zur Gerinnungsoptimierung werden beispielsweise Thrombozyten-Konzentrate, Frischplasma (FFP) oder Prothrombinkomplex-Präparate (PPSB) eingesetzt. Für schwere Blutungen unter dem Thrombin-Inhibitor Dabigatran steht Idarucizumab, für Blutungen unter den Faktor Xa-Inhibitoren Rivaroxaban oder Apixaban steht Andexanet alfa als spezifisches Antidot zur DOAK-Antagonisierung zur Verfügung. Diese Antidote stellen Notfallpräparate dar, die typischerweise erst nach Durchführung leitlinienkonformer multimodaler Maßnahmen einschließlich Notfallendoskopie eingesetzt werden. Eine Antagonisierung oraler Antikoagulanzien sollte bei schwerer gastrointestinaler Blutung in folgenden Situationen erfolgen: (1) refraktärer hämorrhagischer Schock, (2) endoskopisch unstillbare Blutungen, oder (3) nicht vermeidbare Verzögerungen bis zur Notfallendoskopie bei lebensbedrohlicher Blutung. Nach erfolgreicher (endoskopischer) Blutstillung sollte die Antikoagulation (z.B. DOAK, Vitamin-K-Antagonist, Heparin) unter Berücksichtigung des individuellen Blutungsrisikos und des Thromboembolierisikos wieder zeitnah (d.h. in der Regel innerhalb einer Woche) fortgeführt werden.

Abstract

Gastrointestinal (GI) bleeding is one of the most common complications associated with the use of direct oral anticoagulants (DOAC). Clear algorithms exist for the emergency measures in (suspected) GI bleeding, including assessing the medication history regarding anti-platelet drugs and anticoagulants as well as simple coagulation tests during pre-endoscopic management. Platelet transfusions, fresh frozen plasma (FFP), or prothrombin complex concentrate (4F-PCC) are commonly used for optimizing the coagulation status. For severe bleeding under the thrombin inhibitor dabigatran, idarucizumab is available, and for bleeding under the factor Xa inhibitors rivaroxaban or apixaban, andexanet alfa is available as specific antidotes for DOAC antagonization. These antidotes represent emergency drugs that are typically used only after performing guideline-compliant multimodal measures including emergency endoscopy. Antagonization of oral anticoagulants should be considered for severe gastrointestinal bleeding in the following situations: (1) refractory hemorrhagic shock, (2) endoscopically unstoppable bleeding, or (3) nonavoidable delays until emergency endoscopy for life-threatening bleeding. After successful (endoscopic) hemostasis, anticoagulation (DOACs, vitamin K antagonist, heparin) should be resumed timely (i.e. usually within a week), taking into account individual bleeding and thromboembolic risk.

Schlüsselwörter

Antikoagulation - obere gastrointestinale Blutung - Antidote - Leberzirrhose

Keywords

anticoagulation - upper gastrointestinal bleeding - antidot - liver cirrhosis

Full Text

References

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