College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
Am J Health Syst Pharm. 2013 May 15;70(10 Suppl 1):S3-11. doi: 10.2146/ajhp130040.
To describe the mechanisms of action, pharmacokinetics, and rate of bleeding complications from warfarin and target-specific oral anticoagulants; methods for assessing the risk for thromboembolism and bleeding in patients receiving oral anticoagulants or temporarily interrupting such therapy to undergo elective invasive procedures or surgery; therapeutic strategies for balancing these risks; and coagulation assays used to monitor oral anticoagulation therapy.
The target-specific oral anticoagulants have a more specific mechanism of action and shorter elimination half-lives than warfarin, but the half-lives of these target-specific agents may be prolonged in patients with renal impairment or elderly patients, resulting in the potential for drug accumulation and bleeding complications. The rate of bleeding complications in the community setting may be higher than in the clinical trial setting. In patients receiving oral anticoagulants or temporarily interrupting oral anticoagulant therapy to undergo elective invasive procedures or surgery, the risks for thromboembolism and bleeding should be assessed by using validated risk scoring systems and patient stratification schemes. The time during which an oral anticoagulant should be withheld before an invasive procedure or surgery and the time until resumption of therapy after the procedure depend on the drug, risk of thrombosis, type of procedure (i.e., risk for bleeding), and patient-specific variables, especially renal function for the target-specific agents. New coagulation assays are in development for use in monitoring oral anticoagulant therapy.
An individualized approach is needed to balance the risks for thromboembolism and bleeding in patients receiving oral anticoagulants.
描述华法林和靶向口服抗凝剂的作用机制、药代动力学和出血并发症发生率；评估接受口服抗凝剂治疗或暂时中断此类治疗以进行择期侵入性操作或手术的患者发生血栓栓塞和出血风险的方法；平衡这些风险的治疗策略；以及用于监测口服抗凝治疗的凝血检测方法。
与华法林相比，靶向口服抗凝剂具有更特异的作用机制和更短的消除半衰期，但在肾功能损害或老年患者中，这些靶向药物的半衰期可能延长，导致药物蓄积和出血并发症的潜在风险。在社区环境中，出血并发症的发生率可能高于临床试验环境。对于接受口服抗凝剂治疗或暂时中断口服抗凝剂治疗以进行择期侵入性操作或手术的患者，应使用经过验证的风险评分系统和患者分层方案评估血栓栓塞和出血风险。在侵入性操作或手术前应停止口服抗凝剂的时间以及在操作后恢复治疗的时间取决于药物、血栓形成风险、操作类型（即出血风险）和患者特定变量，特别是靶向药物的肾功能。正在开发新的凝血检测方法用于监测口服抗凝治疗。
需要采用个体化方法来平衡接受口服抗凝剂治疗的患者的血栓栓塞和出血风险。
