Pahs Lesley, Beavers Craig, Schuler Patricia
From the *Pharmacy Practice Resident, Centennial Medical Center, 2300 Patterson Street, Nashville, TN 37203; †Clinical Pharmacy Specialist, Cardiology, TriStar Centennial Medical Center, 2300 Patterson Street, Nashville, TN 37203; and ‡ Clinical Pharmacy Specialist, Cardiology, Roper Hospital, 316 Calhoun Street, Charleston, SC 29401.
Crit Pathw Cardiol. 2015 Jun;14(2):53-61. doi: 10.1097/HPC.0000000000000042.
Adoption of the target-specific oral anticoagulants (TSOACs) has been slow; accordingly, lack of guidance for emergent reversal confounded by the need for "direct" reversal agents has contributed significantly to warfarin entrenchment in the medical community. The purpose of this analysis is to provide real-world experiences regarding the management of the hemorrhaging patient secondary to dabigatran and rivaroxaban.
Retrospective review of patients admitted with a hemorrhage secondary to dabigatran or rivaroxaban were evaluated. Descriptive statistics were utilized for analysis.
Four hundred forty-four patients were screened for inclusion into the study; notably, 419 (94%) of the patients were excluded because the bleed was secondary to warfarin therapy. Of those included in this analysis (n = 25), gastrointestinal bleeding accounted for 21 events (84%), followed by intracranial (n = 2; 8%) and epistaxis (n = 2; 8%). Two patients (8%) expired during admission and 6 patients (24%) expired within 6 months after discharge from the hospital. Three (12%) minor bleeds, 7 (28%) major bleeds, and 15 (60%) life-threatening bleeds were identified. Minor bleeds required careful monitoring, supportive care, and cessation of anticoagulation therapy, whereas increasing severity required multiple interventions with prothrombin complex concentrate, recombinant activated factor 7, fresh frozen plasma, packed red blood cells, cryoprecipitate, and platelets.
The approach to the management of bleeding events borne from TSOACs has proven to be very heterogeneous. In the midst of this observation period, these facilities developed protocols, which created a stratification of bleeds and a more regimented approach to managing them. Although bleeding is less with new agents, the creation of pathways/algorithms for the management of TSOACs and education regarding clinical decision-making may be beneficial for the expeditious and appropriate management when these events arise.
靶向特异性口服抗凝剂（TSOACs）的应用进展缓慢；因此，由于需要“直接”逆转剂而导致的紧急逆转缺乏指导，这在很大程度上导致了华法林在医学界的根深蒂固。本分析的目的是提供关于达比加群和利伐沙班所致出血患者管理的真实世界经验。
对因达比加群或利伐沙班继发出血而入院的患者进行回顾性评估。采用描述性统计进行分析。
共筛选了444例患者纳入本研究；值得注意的是，419例（94%）患者因出血继发于华法林治疗而被排除。在纳入本分析的患者中（n = 25），胃肠道出血占21例（84%），其次是颅内出血（n = 2；8%）和鼻出血（n = 2；8%）。2例患者（8%）在住院期间死亡，6例患者（24%）在出院后6个月内死亡。确定了3例（12%）轻微出血、7例（28%）严重出血和15例（60%）危及生命的出血。轻微出血需要仔细监测、支持性治疗和停止抗凝治疗，而随着出血严重程度增加，则需要多种干预措施，包括使用凝血酶原复合物浓缩物、重组活化因子7、新鲜冰冻血浆、浓缩红细胞、冷沉淀和血小板。
事实证明，TSOACs所致出血事件的管理方法非常不一致。在本观察期内，这些机构制定了方案，对出血进行分层，并采用更规范的方法进行管理。尽管新型药物导致的出血较少，但制定TSOACs管理的途径/算法以及关于临床决策的教育，可能有利于在这些事件发生时进行快速、恰当的管理。
