Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
Section of Angiology, Center of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany.
Thromb Haemost. 2020 Jun;120(6):899-911. doi: 10.1055/s-0040-1710314. Epub 2020 Jun 3.
As a result of the successful completion of their respective phase III studies compared with vitamin K antagonists (VKAs), four direct oral anticoagulants (DOACs) have been approved for the treatment and secondary prevention of venous thromboembolism (VTE). These DOACs-apixaban, dabigatran, edoxaban, and rivaroxaban-have subsequently seen a steady uptake among clinicians since their approval. Despite the suitability of DOACs for a broad range of patients, they are not appropriate in certain situations, whereas in others they require additional considerations such as dose reductions. Subanalyses of phase III trials and studies on specific VTE patient populations have been conducted to evaluate the safety and efficacy of the DOACs in a broad range of settings, such as patients with renal impairment, patients with cancer, patients of childbearing potential, patients with multiple comorbidities and pediatric patients. Furthermore, many recent guidance documents from important hematological societies and other specialists have incorporated several of these developments. These documents also identify the patients for whom DOACs are not suitable and where traditional anticoagulation options such as heparins or VKAs should be considered instead. This review provides an overview of key VTE patient subgroups, the clinical evidence supporting the use of anticoagulation in these patients, and a discussion of the most appropriate approaches to their management, including considerations such as dosing, acute and extended treatment durations, and DOAC selection.
由于在与维生素 K 拮抗剂（VKA）的 III 期研究中取得成功，四种直接口服抗凝剂（DOAC）已获准用于治疗和静脉血栓栓塞症（VTE）的二级预防。这些 DOAC-阿哌沙班、达比加群、依度沙班和利伐沙班-自获得批准以来，在临床医生中稳步采用。尽管 DOAC 适用于广泛的患者，但在某些情况下并不适用，而在其他情况下，它们需要额外的考虑，如剂量减少。III 期试验和特定 VTE 患者人群的亚分析已经进行，以评估 DOAC 在广泛的环境中的安全性和疗效，例如肾功能不全的患者、癌症患者、有生育潜力的患者、患有多种合并症的患者和儿科患者。此外，许多重要的血液病学会和其他专家的最新指南文件也纳入了其中的一些发展。这些文件还确定了不适合使用 DOAC 的患者，以及应考虑使用传统抗凝药物（如肝素或 VKA）的情况。这篇综述提供了关键 VTE 患者亚组的概述、支持在这些患者中使用抗凝治疗的临床证据，并讨论了最适合这些患者管理的方法，包括剂量、急性和延长治疗时间以及 DOAC 选择等方面的考虑。
