Vitamin K antagonists

Summary

For the last decades, anticoagulation for stroke prevention in atrial fibrillation (AF) as well as for the prophylaxis and long-term treatment of venous thromboembolism has been entirely based on vitamin K antagonists (VKA). Although very effective under optimal conditions, long-term treatment with these drugs is flawed by the fact that the time in the therapeutic range frequently is suboptimal due to biological factors, drug interactions and compliance.

The direct thrombin inhibitor dabigatran, as well as the direct FXa inhibitors rivaroxaban and apixaban provide more consistent anticoagulation and have proven their efficacy and safety against VKAs in several large scale randomized clinical trials for stroke prevention in atrial fibrillation as well as for the treatment and prevention of venous thromboembolism. In view of these convincing data and other advantages such as the lack of mandatory monitoring and only few drug interactions,VKAs will most likely be replaced in a majority of patients for these indications. Based on the most recent trial evidence, the current review discusses the role of VKA treatmentand that of the novel anticoagulants.

Zusammenfassung

Während der vergangenen Jahrzehnte kamen zur Schlaganfallprophylaxe bei Vorhofflimmern sowie zur Behandlung der venösen Thromboembolie in erster Linie Vitamin-KAntagonisten zum Einsatz. Obgleich diese unter optimalen Bedingungen sehr effektiv und verhältnismäßig sicher sind, wird ihre Langzeitanwendung durch häufige Quickbzw. INR-Schwankungen bedingt durch die zahlreichen Medikamenten- und Arzneimittelnebenwirkungen sowie Complianceproblematik beeinträchtigt.

Der direkte Thrombinhemmer Dabigatran sowie die Faktor-Xa-Inhibitoren Rivaroxaban und Apixaban bewirken eine verlässlichere Blutverdünnung, und haben verglichen mit den Vitamin-K-Antagonisten in großen klinischen Studien sowohl beim Vorhofflimmern als auch in der Behandlung der venösen Thromboembolie eine bessere Effizienz und Sicherheit gezeigt. In Anbetracht der überzeugenden Datenlage sowie weiterer Vorteile wie fehlender Notwendigkeit eines Monitorings und selteneren Medikamenteninteraktionen ist davon auszugehen, dass Vitamin-K-Antagonisten wohl in der Mehrzahl der Fälle durch die neuen Antikoagulanzien ersetzt werden. In diesem Review wird, basierend auf den Ergebnissen der Studien, die Rolle der Vitamin-K-Antagonisten und der neuen Antikoagulanzien diskutiert.

Keywords

Apixaban - atrial fibrillation - dabigatran - ovel oral anticoagulants - rivaroxaban - RE-LY - AVERROES - ARISTOTLE - ROCKET AF

Schlüsselwörter

Apixaban - Vorhofflimmern - dabigatran - neue orale Antikoagulanzien - Rivaroxaban - RE-LY - AVERROES - ARISTOTLE - ROCKET AF

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