RESUMO
PURPOSE OF REVIEW: The purpose of this review was to offer practical management strategies for when patients receiving direct oral anticoagulants require elective surgery or present with bleeding complications. RECENT FINDINGS: Clinical practice guidelines are now available on the timing of periprocedural interruption of treatment with the newer direct oral anticoagulants based on their pharmacodynamics and pharmacokinetics and based on findings from cohort studies and clinical trials. An antibody that reverses the effects of dabigatran is now available, and a factor Xa decoy is being developed as an antidote to apixaban, betrixaban, edoxaban, and rivaroxaban. The timing of interruption of direct oral anticoagulants for elective surgery is based on multiple factors, including pharmacologic properties and interactions, the patient's renal function, and the type of planned surgery. There is little role for low-molecular-weight heparin bridging. Idarucizumab is the treatment of choice for dabigatran-related life-threatening bleeding, while andexanet alfa is being developed to reverse factor Xa inhibitors.
Assuntos
Anticoagulantes/uso terapêutico , Desprescrições , Procedimentos Cirúrgicos Eletivos/métodos , Hemorragia/prevenção & controle , Guias de Prática Clínica como Assunto , Administração Oral , Anticorpos Monoclonais Humanizados/uso terapêutico , Antídotos/uso terapêutico , Antitrombinas/uso terapêutico , Benzamidas/uso terapêutico , Perda Sanguínea Cirúrgica , Dabigatrana/uso terapêutico , Fator Xa/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Humanos , Pirazóis/uso terapêutico , Piridinas/uso terapêutico , Piridonas/uso terapêutico , Proteínas Recombinantes/uso terapêutico , Rivaroxabana/uso terapêutico , Tiazóis/uso terapêuticoAssuntos
Erros de Diagnóstico/prevenção & controle , Infecções por HIV , Neurossífilis , Penicilina G/administração & dosagem , Transtornos Psicóticos/diagnóstico , Adulto , Antibacterianos/administração & dosagem , Diagnóstico Diferencial , Infecções por HIV/complicações , Infecções por HIV/diagnóstico , Humanos , Masculino , Neurossífilis/complicações , Neurossífilis/diagnóstico , Neurossífilis/tratamento farmacológico , Resultado do TratamentoAssuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Complicações Intraoperatórias/epidemiologia , Assistência Perioperatória/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Humanos , Assistência Perioperatória/efeitos adversos , Medição de Risco/métodos , Fatores de RiscoRESUMO
Approximately half of patients started on an oral anticoagulant in the USA now receive one of the newer direct oral anticoagulants (DOACs). Although there is an approved reversal agent for the direct thrombin inhibitor dabigatran, a specific reversal agent for the anti-factor Xa (FXa) DOACs has yet to be licensed. Unlike the strategy to reverse the only oral direct thrombin inhibitor with idarucizumab, which is a humanized monoclonal antibody fragment, a different approach is necessary to design a single agent that can reverse multiple anti-FXa medications. Andexanet alfa is a FXa decoy designed to reverse all anticoagulants that act through this part of the coagulation cascade including anti-FXa DOACs, such as apixaban, edoxaban and rivaroxaban, and indirect FXa inhibitors such as low-molecular-weight heparins. This narrative reviews the development of andexanet alfa and explores its basic science, pharmacokinetics/pharmacodynamics, animal models, and human studies.
RESUMO
After anticoagulation has been started in patients with venous thromboembolism (VTE), three issues need to be addressed: the length of therapy, measures to help prevent postthrombotic syndrome, and a basic workup for malignancy in patients with idiopathic VTE.