Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX, USA.
Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA.
Dig Dis Sci. 2021 Nov;66(11):3698-3714. doi: 10.1007/s10620-020-06728-y. Epub 2021 Jan 6.
Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa).
To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed.
This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data.
GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications.
The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.
接受抗凝治疗的患者，如维生素 K 拮抗剂（VKAs）或直接口服抗凝剂（DOACs），常因并发症出现胃肠道（GI）出血，可能需要在进行内镜治疗前进行抗凝逆转。抗凝逆转剂包括凝血酶原复合物浓缩物（PCCs；包括 3 或 4 种凝血因子）、血浆、维生素 K 以及针对特定 DOAC 的逆转剂（如依达鲁单抗和andexanet alfa）。
综述目前美国和国际上有关 VKAs 或 DOAC 患者在接受内镜治疗前因 GI 出血而使用抗凝逆转剂的指南，包括基于指南的凝血缺陷管理、内镜治疗时机以及止血后恢复抗凝治疗的建议。还回顾了支持这些建议的临床数据。
这是一篇基于文献综述，检索了报道 GI 指南和支持临床数据的 PubMed 和互联网资源。
针对 GI 的特定指南指出，对于有生命威胁的 GI 出血患者应考虑使用逆转剂。对于国际标准化比值（INR）＞2.5 的 VKA 患者，指南建议使用 PCCs（特别是 4F-PCC），因为与新鲜冷冻血浆相比，它们在逆转 VKA 相关的 GI 出血方面可能具有更高的疗效/安全性。对于 DOAC 患者，大多数指南建议在 GI 出血时使用针对特定的逆转剂；然而，PCCs（主要是 4F-PCC）也常被列为另一种选择。停止 GI 出血后，也建议恢复抗凝治疗，以降低未来血栓栓塞并发症的风险。
指南中认识到了抗凝逆转剂在 GI 出血中的应用，但这些药物应保留用于真正危及生命的情况。
