Desai Nihar R, Cornutt David
Center for Outcomes Research and Evaluation, Yale-New Haven Health System , New Haven , CT , USA.
Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine , New Haven , CT , USA.
Hosp Pract (1995). 2019 Aug;47(3):113-122. doi: 10.1080/21548331.2019.1643728. Epub 2019 Jul 29.
Direct oral anticoagulants (DOACs) include dabigatran etexilate, a direct thrombin inhibitor, and specific inhibitors of activated coagulation factor X (FXa; e.g. apixaban, betrixaban, edoxaban, rivaroxaban). DOACs are associated with lower rates of major and fatal bleeding events compared with warfarin. Clinicians may need to achieve rapid reversal of anticoagulation effects of the DOACs in an emergency setting. Idarucizumab and andexanet alfa, which reverse the anticoagulant effects of dabigatran and FXa inhibitors, respectively, are DOAC reversal agents available in the US. Other reversal agents (e.g. ciraparantag for heparins, DOACs) are in development. Alternative nonspecific agents (e.g. fresh frozen plasma, prothrombin complex concentrate) are available. Nonspecific prohemostatic agents can counteract the anticoagulant action of DOACs in emergency situations, when specific reversal agents are unavailable. However, specific reversal agents are efficacious and safe and should be preferred when available. In this review, we discuss practical issues in the initiation of DOAC therapy, situations where reversal may be needed, coagulation assays, reversal agents, and post-reversal complications in the context of published evidence and guidelines.
直接口服抗凝剂（DOACs）包括直接凝血酶抑制剂达比加群酯，以及活化凝血因子X（FXa）的特异性抑制剂（如阿哌沙班、贝曲西班、依度沙班、利伐沙班）。与华法林相比，DOACs发生严重和致命出血事件的几率较低。在紧急情况下，临床医生可能需要迅速逆转DOACs的抗凝作用。达比加群酯和FXa抑制剂抗凝作用的逆转剂分别为艾达赛珠单抗和安多昔单抗α，它们在美国是可用的DOAC逆转剂。其他逆转剂（如用于肝素、DOACs的西帕曲班）正在研发中。也有其他非特异性药物（如新鲜冰冻血浆、凝血酶原复合物浓缩剂）可用。当没有特异性逆转剂时，非特异性促止血药物在紧急情况下可抵消DOACs的抗凝作用。然而，特异性逆转剂有效且安全，如有可用应优先选择。在本综述中，我们结合已发表的证据和指南，讨论DOAC治疗起始的实际问题、可能需要逆转的情况、凝血检测、逆转剂以及逆转后的并发症。
