Zusammenfassung
Seit wenigen Monaten sind neue orale Antikoagulanzien für die Prävention von Schlaganfällen bei Vorhofflimmern verfügbar, darunter der reversible Thrombininhibitor Dabigatran und der Faktor Xa-Hemmer Rivaroxaban. Die Substanzen werden teilweise als überlegene Alternative zu den Vitamin-K-Antagonisten angesehen und die Nichtnotwendigkeit eines Gerinnungsmonitorings wird als besonderer Vorteil herausgestellt. Obgleich Vorhofflimmern eine Erkrankung vor allem des höheren Lebensalters ist, wurde die Eignung dieser Wirkstoffe bei multimorbiden geriatrischen Patienten bisher noch wenig untersucht. Bei Dabigatran kommt aufgrund der Niereninsuffizienz als Kontraindikation in dieser Population i.d.R. nur die niedrigere der beiden zugelassenen Dosierungen zum Einsatz. Bei dieser konnte jedoch keine therapeutische Überlegenheit, sondern lediglich eine verminderte Rate schwerer Blutungen als Komplikation gezeigt werden, allerdings bei sehr hoher „number needed to treat“. Die Notwendigkeit der zweimal täglichen Einnahme dieser Substanz, das Fehlen einer Monitoringoption, die vergleichsweise kurze Wirkdauer und das Fehlen eines Antidots könnten sich in der täglichen Praxis sogar als entscheidender Nachteil gegenüber Vitamin K-Antagonisten erweisen. Bis zum Vorliegen weiterer Daten sollten die neuen Antikoagulanzien bei geriatrischen Patienten nur zurückhaltend verordnet werden.
Abstract
New oral anticoagulants for the prevention of stroke in patients with nonvalvular atrial fibrillation have been available for a few months, among them the reversible direct thrombin inhibitor dabigatran and the factor Xa antagonist rivaroxaban. These drugs are considered by some as a superior alternative to vitamin K antagonists. The lack of necessity for regular monitoring is advertised as a major advantage. Although atrial fibrillation is a disease with increasing prevalence with higher age, the suitability of the new drugs has not been extensively studied in multimorbid geriatric patients. Since dabigatran is contraindicated in patients with renal insufficiency, only the lower of the two approved dosages can usually be prescribed in elderly patients. For the lower dosage, however, no superiority in prevention of stroke has been documented but merely a reduction in major bleeding rates, although at a high number needed to treat. The requirement for a twice-daily dosage regimen, the lack of an anticoagulation monitoring option, the relatively short duration of action and the lack of an antidote may even prove to be crucial disadvantages in clinical practice in comparison to vitamin K antagonists. Until more data are available, the new oral anticoagulants should be prescribed with caution in geriatric patients.
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Berthold, H. Neue orale Antikoagulanzien zur Schlaganfallprävention. Z Gerontol Geriat 45, 498–504 (2012). https://doi.org/10.1007/s00391-012-0377-4
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DOI: https://doi.org/10.1007/s00391-012-0377-4