Deutsch David, Boustière Christian, Ferrari Emile, Albaladejo Pierre, Morange Pierre-Emmanuel, Benamouzig Robert
Hopital Avicenne, 125 rue de Stalingrad, Bobigny, 93000, France.
Hopital Saint Joseph, Marseille, Provence-Alpes-Côte d'Azur, France.
Therap Adv Gastroenterol. 2017 Jun;10(6):495-505. doi: 10.1177/1756283X17702092. Epub 2017 Apr 17.
The use of direct oral anticoagulants (DOACs) was an important step forward in the management of atrial fibrillation and venous thromboembolism (VTE). The DOACs, anti-IIa for dabigatran and anti-Xa for rivaroxaban, apixaban and edoxaban, all have a rapid onset of action and a short half life. There is no need for routine hemostasis testing for treatment monitoring of a DOAC. Compared with vitamin K antagonists (VKAs), DOACs may increase the risk of gastrointestinal bleeding (relative risk 1.25). Withholding the DOAC treatment, evaluating the time of the last intake and estimating the patient's renal function are the first steps in the management of gastrointestinal bleeding. For patients without impaired renal function, achieving low coagulation takes around 24 h after the last intake of a DOAC. The use of DOAC antagonists will be helpful in controlling bleeding in the most severe and urgent situations. Idarucizumab is available for clinical use for dabigatran and andexanet is currently being reviewed by drug agencies for rivaroxaban, apixaban and edoxaban. It is important to assess the bleeding risk associated with the planned procedure, and the patient's renal function before withholding DOAC therapy for a scheduled intervention. It is mandatory to strengthen the local hemostasis strategies in DOAC-treated patients undergoing a therapeutic endoscopic procedure. Resuming or not resuming anticoagulation with a DOAC after bleeding or a risky procedure depends on the thrombotic and bleeding risk as well as the procedure involved. This discussion should always involve the cardiologist and decisions should be taken by a pluridisciplinary team.
直接口服抗凝剂（DOACs）的使用是心房颤动和静脉血栓栓塞（VTE）管理方面向前迈出的重要一步。DOACs中，达比加群为抗凝血酶IIa制剂，利伐沙班、阿哌沙班和依度沙班为抗凝血因子Xa制剂，它们均起效迅速且半衰期短。治疗监测DOACs时无需进行常规止血检测。与维生素K拮抗剂（VKAs）相比，DOACs可能会增加胃肠道出血风险（相对风险1.25）。停用DOAC治疗、评估末次服药时间并估算患者肾功能是胃肠道出血管理的首要步骤。对于肾功能未受损的患者，末次服用DOAC后约24小时凝血功能会降低。在最严重和紧急的情况下，使用DOAC拮抗剂有助于控制出血。艾达赛珠单抗可用于临床治疗达比加群中毒，而andexanet目前正在接受药物机构对利伐沙班、阿哌沙班和依度沙班的审查。在因计划中的手术而停用DOAC治疗之前，评估与手术相关的出血风险以及患者的肾功能非常重要。对于接受治疗性内镜手术的DOAC治疗患者，必须加强局部止血策略。出血或进行有风险的手术后是否恢复使用DOAC抗凝取决于血栓形成和出血风险以及所涉及的手术。这种讨论应始终包括心脏病专家，决策应由多学科团队做出。
