Karen Lipworth
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引用次数: 0

摘要

教师们一致认为,尽管直接口服抗凝剂(DOAC)与维生素K拮抗剂相比已经取得了重大进展,但它们的利用仍然不够理想,这通常是由于许多类型的患者普遍担心出血。由于出血的风险和影响,老年本身可能是停止抗凝治疗的一个原因。虚弱和合并症,如慢性肾脏疾病(CKD),会对doac的生物利用度产生不利影响,也会阻碍最佳抗凝剂的使用。临床医生可能会试图通过不适当地开低剂量的DOACs来避免或减轻出血,这是一种已被发现不能保护患者免受血栓形成风险的标签外做法,也不能降低出血风险。此外,潜在的药物-药物相互作用和较差的依从性也限制了doac在现实世界临床实践中的最佳使用。最近的一项关于“轻微出血”的患者调查,通常被临床医生称为“讨厌的出血”,通常在临床试验中没有很好地抓住,揭示了持续出血问题对生活质量的深远影响,这些经历可能会阻止患者坚持他们的抗凝治疗方案。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Improving the Effectiveness of Anticoagulant Therapy: The Promise of Factor XI Inhibition
This continuing medical education-accredited symposium, held at the 2023 International Society for Thrombosis and Haemostasis (ISTH) congress in Montréal, Canada, focused on current unmet needs in anticoagulation, especially in the atrial fibrillation (AF) population, and reflected on the promise of the emerging class of Factor XI inhibitors for stroke prevention (SPAF) in susceptible patients. The faculty agreed that, although direct oral anticoagulants (DOAC) have represented a major advance compared with vitamin K antagonists, their utilisation remains suboptimal, often due to the prevailing fear of bleeding in many types of patients. Older age alone can be a reason for withholding anticoagulation, due to the risk and implications of bleeding. Frailty and comorbidities, such as chronic kidney disease (CKD), which can adversely affect the bioavailability of DOACs, are also deterrents to optimal anticoagulant use. Clinicians may try to avoid or mitigate bleeding by inappropriately prescribing low doses of DOACs, an off-label practice that has been found to fail to protect patients from thrombotic risk, without attenuating the risk of bleeding. In addition, the potential for drug-drug interactions and poor adherence also limit the optimal use of DOACs in real-world clinical practice. A recent patient survey focusing on the topic of ‘minor bleeding’, often referred to by clinicians as ‘nuisance bleeding’, and typically not well captured in clinical trials, revealed the far-reaching impact of ongoing problems with bleeding on quality of life, and the possibility that these experiences may deter patients from adherence to their prescribed anticoagulant regimen. Factor XI represents a promising new target for anticoagulation, which may minimise the risk of bleeding by pharmacologically ‘uncoupling’ the clotting pathway, leading to pathological thrombosis from the cascade largely responsible for physiological haemostasis. Phase II research with investigational Factor XI inhibitors has established their antithrombotic and safety potential, and some of these agents may also avoid other practical drawbacks of DOACs. Phase III evaluation of Factor XI inhibition is ongoing in a number of clinical settings.
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