Walter Ageno, MD, University of Insubria, Varese, Italy, E-mail:
Thromb Haemost. 2016 Nov 30;116(6):1003-1010. doi: 10.1160/TH16-05-0363. Epub 2016 Aug 4.
Anticoagulation is the cornerstone of prevention and treatment of venous thromboembolism (VTE) and stroke prevention in patients with atrial fibrillation (AF). However, the mechanisms by which anticoagulants confer therapeutic benefit also increase the risk of bleeding. As such, reversal strategies are critical. Until recently, the direct oral anticoagulants (DOACs) dabigatran, rivaroxaban, apixaban, and edoxaban lacked a specific reversal agent. This report is based on findings from the Anticoagulation Education Task Force, which brought together patient groups and professionals representing different medical specialties with an interest in patient safety and expertise in AF, VTE, stroke, anticoagulation, and reversal agents, to discuss the current status of anticoagulation reversal and fundamental changes in management of bleeding associated with DOACs occasioned by the approval of idarucizumab, a specific reversal agent for dabigatran, as well as recent clinical data on specific reversal agents for factor Xa inhibitors. Recommendations are given for when there is a definite need for a reversal agent (e.g. in cases of life-threatening bleeding, bleeding into a closed space or organ, persistent bleeding despite local haemostatic measures, and need for urgent interventions and/or interventions that carry a high risk for bleeding), when reversal agents may be helpful, and when a reversal agent is generally not needed. Key stakeholders who require 24-7/around-the-clock access to these agents vary among hospitals; however, from a practical perspective the emergency department is recommended as an appropriate location for these agents. Clearly, the advent of new agents requires standardised protocols for treating bleeding on an institutional level.
抗凝治疗是预防和治疗静脉血栓栓塞症（VTE）和预防心房颤动（AF）患者中风的基石。然而，抗凝剂发挥治疗作用的机制也会增加出血的风险。因此，逆转策略至关重要。直到最近，直接口服抗凝剂（DOACs）达比加群、利伐沙班、阿哌沙班和依度沙班都缺乏特定的逆转剂。本报告基于抗凝教育工作组的发现，该工作组汇集了患者群体和代表不同医学专业的专业人员，他们对患者安全和 AF、VTE、中风、抗凝和逆转剂方面的专业知识感兴趣，讨论了目前抗凝逆转的现状以及由于达比加群的特定逆转剂依达鲁单抗的批准，以及最近关于新型 Xa 因子抑制剂的特定逆转剂的临床数据，对 DOACs 相关出血管理的基本变化。建议在明确需要逆转剂的情况下（例如，在危及生命的出血、出血进入密闭空间或器官、尽管进行了局部止血措施仍持续出血、需要紧急干预和/或存在高出血风险的干预时），在可能需要逆转剂时，以及在通常不需要逆转剂时使用。需要 24 小时/全天候获得这些药物的关键利益相关者在不同医院有所不同；然而，从实际角度来看，推荐将急诊科作为这些药物的适当位置。显然，新型药物的出现需要在机构层面上制定治疗出血的标准化方案。
