Chang Clement, Hoyos Mario, Owusu Yaw, Elewa Hazem
1 Purdue University, West Lafayette, IN, USA.
2 Qatar University, Doha, Qatar.
Ann Pharmacother. 2018 Feb;52(2):185-197. doi: 10.1177/1060028017731850. Epub 2017 Sep 16.
To review the published literature for evidence of the efficacy and safety of direct oral anticoagulants (DOACs) when used in the management of atypical thrombosis-related conditions.
A comprehensive MEDLINE database search (1948 to July 2017) and EMBASE search (1980 to July 2017) were conducted using the search terms direct oral anticoagulant in combination with acute coronary syndrome (ACS), antiphospholipid antibody syndrome (APLAS), and cancer-associated thrombosis (CAT).
The literature search was limited to studies that were conducted in humans and published in English. Clinical trials, observational studies, and case series were selected.
A total of 20 published studies were selected from the literature. Only 1 randomized controlled study showed a significant reduction in cardiovascular outcomes on DOAC use in ACS patients but at the expense of increased bleeding. For the use of DOACs in APLAS, the evidence from case series seems to suggest low incidence of thromboembolic events or recurrent thrombosis in low-risk patients. Finally, in cancer patients, DOACs were comparable to warfarin in preventing CAT in 8 studies of different designs. Major bleeding with DOACs was not significantly lower than in patients who received an enoxaparin/warfarin regimen.
Until more evidence from the ongoing clinical trials is available, DOACs may not be favorable add-on therapy in ACS patients receiving standard antiplatelet therapy but may be alternative to warfarin in preventing or treating thrombosis in low-risk APLAS patients as well as in cases of CAT in which patients have to be managed with warfarin.
回顾已发表文献,以寻找直接口服抗凝剂(DOACs)用于治疗非典型血栓相关疾病时有效性和安全性的证据。
使用搜索词“直接口服抗凝剂”与“急性冠脉综合征(ACS)”、“抗磷脂抗体综合征(APLAS)”及“癌症相关血栓形成(CAT)”相结合,对MEDLINE数据库(1948年至2017年7月)和EMBASE数据库(1980年至2017年7月)进行全面检索。
文献检索限于在人类中开展并以英文发表的研究。选取了临床试验、观察性研究及病例系列。
从文献中总共选取了20项已发表研究。仅有1项随机对照研究显示,ACS患者使用DOACs可显著降低心血管事件,但代价是出血增加。对于DOACs在APLAS中的应用,病例系列证据似乎表明,低风险患者血栓栓塞事件或复发性血栓形成的发生率较低。最后,在癌症患者中,在8项不同设计的研究中,DOACs在预防CAT方面与华法林相当。DOACs导致的大出血并不显著低于接受依诺肝素/华法林治疗方案的患者。
在获得正在进行的临床试验的更多证据之前,DOACs可能不是接受标准抗血小板治疗的ACS患者的理想附加治疗,但在预防或治疗低风险APLAS患者的血栓形成以及必须使用华法林治疗的CAT病例中,可能是华法林的替代药物。