Atia R, Bonnel S, Vallos M, Laroche L, Borderie V, Bouheraoua N
Service d'ophtalmologie 5, centre national d'ophtalmologie des Quinze-Vingts, UPMC, Sorbonne université, 28, rue de Charenton, 75012 Paris, France.
Service d'hématologie, hôpital de la pitié salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
J Fr Ophtalmol. 2018 Oct;41(8):767-772. doi: 10.1016/j.jfo.2018.01.007. Epub 2018 Sep 11.
New direct oral anticoagulants (DOAC) have been approved for treatment and prevention of some thromboembolic diseases: acute and chronic phase of thromboembolic disease, deep venous thrombosis prophylaxis in orthopedic surgery and prevention of stroke in patients with atrial fibrillation. These molecules are an alternative to heparins and vitamin K antagonists. Among these, rivaroxaban (Xarelto, Bayer Schering Pharma) is a direct factor Xa inhibitor, and dabigatran etexilate (Pradaxa, Boehringer Ingelheim) is a direct free thrombin inhibitor. These molecules are almost the ideal anticoagulant: oral administration, few drug and food interactions, wide therapeutic target, and especially no lab monitoring. However, their use remains associated with hemorrhagic complications such as gastrointestinal, intracranial or urinary hemorrhages. We describe two clinical cases of spontaneous choroidal hemorrhage in patients treated with direct oral anticoagulants (rivaroxaban and dabigatran etexilate) for atrial fibrillation. These cases show that an ocular hemorrhagic risk exists with these drugs. Patients treated with DOAC should have the therapeutic dose adjusted based on creatinine clearance. Special monitoring should be performed in patients with age-related macular degeneration or with hypertension even though meta-analysis shows that the risk of intraocular bleeding is reduced by 22% compared with warfarin.
新型直接口服抗凝剂（DOAC）已被批准用于治疗和预防某些血栓栓塞性疾病：血栓栓塞性疾病的急性期和慢性期、骨科手术中的深静脉血栓形成预防以及心房颤动患者的中风预防。这些分子是肝素和维生素K拮抗剂的替代品。其中，利伐沙班（拜瑞妥，拜耳先灵医药公司）是一种直接的Xa因子抑制剂，达比加群酯（泰毕全，勃林格殷格翰公司）是一种直接的游离凝血酶抑制剂。这些分子几乎是理想的抗凝剂：口服给药、药物与食物相互作用少、治疗靶点广泛，尤其是无需实验室监测。然而，它们的使用仍与出血并发症相关，如胃肠道、颅内或泌尿系统出血。我们描述了两例因心房颤动接受直接口服抗凝剂（利伐沙班和达比加群酯）治疗的患者发生自发性脉络膜出血的临床病例。这些病例表明，使用这些药物存在眼部出血风险。接受DOAC治疗的患者应根据肌酐清除率调整治疗剂量。即使荟萃分析显示与华法林相比眼内出血风险降低了22%，对于年龄相关性黄斑变性患者或高血压患者仍应进行特殊监测。
