直接作用口服抗凝剂的实验室和临床监测:临床医生需要知道什么

S. Conway, Andrew Y. Hwang, C. Ponte, J. Gums
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引用次数: 92

摘要

直接作用口服抗凝剂(DOACs),包括达比加群、利伐沙班、阿哌沙班和依多沙班,具有良好的药代动力学和药效学特性,与华法林相比具有同等或更好的疗效和更高的安全性。DOACs的缺点是半衰期较短,需要更严格的依从性,缺乏标准化的实验室监测,缺乏抗凝逆转剂,缺乏常规凝血监测导致患者与临床相互作用较少。本综述解决了其中的许多局限性,包括监测doac的功效和毒性,评估选定的定性和定量试验,以及制定针对特殊人群的监测战略。凝血监测通常只推荐在药物过量的情况下使用,但是一旦标准化的检测方法易于获得,它们将有助于确保疗效,评估出血,并帮助在许多其他患者情况下进行药物选择。凝血试验可提供定性评估,包括活化部分凝血活酶时间、凝血酶原时间和凝血酶时间。定量评估DOACs的潜在实用方法包括血浆药物浓度、凝血酶凝血时间、稀释凝血酶时间和抗Xa因子浓度。非凝血实验室监测应包括血清肌酐、肝功能检查和全血细胞计数。对DOAC治疗患者的临床监测应包括依从性、出血风险和药物相互作用的常规评估。监测频率应在开始治疗后1-3个月,然后至少每6个月进行一次,并根据患者的具体特征(如年龄、肾功能损害、肝功能损害和伴随的药物治疗)进行更频繁的随访(即3个月)。作者提供了一个实用的工具,以协助DOAC监测,并建议药剂师与医生合作,选择合适的患者和定制患者特定的监测计划。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Laboratory and Clinical Monitoring of Direct Acting Oral Anticoagulants: What Clinicians Need to Know
The direct acting oral anticoagulants (DOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban, have favorable pharmacokinetic and pharmacodynamic properties and equal or superior efficacy and an improved safety profile compared with warfarin. Noted shortcomings with DOACs are shorter half‐lives requiring stricter adherence, lack of standardized laboratory monitoring, lack of anticoagulation reversal agents, and loss of routine coagulation monitoring leading to fewer patient–clinician interactions. This review addresses many of these limitations including monitoring of DOACs for efficacy and toxicity, an assessment of selected qualitative and quantitative tests, and development of monitoring strategies for special populations. Coagulation monitoring is generally recommended only in overdose situations, but once standardized assays are readily available, they could be helpful to ensure efficacy, assess bleeding, and aid in drug selection in a number of other patient scenarios. Coagulation tests that may provide qualitative assessment include activated partial thromboplastin time, prothrombin time, and thrombin time. Methods with potential utility for quantitative assessment of DOACs include plasma drug concentrations, ecarin clotting time, dilute thrombin time, and anti–factor Xa concentrations. Noncoagulation laboratory monitoring should include serum creatinine, liver function tests, and complete blood counts. Clinical monitoring of the DOAC‐treated patient should include routine assessment of adherence, bleeding risks, and drug interactions. Frequency of monitoring should be 1–3 months after initiation and then at least every 6 months, with more frequent follow‐up (i.e., 3 months) based on patient specific characteristics such as age, renal impairment, hepatic impairment, and concomitant drug therapy. The authors provide a practical tool to assist in DOAC monitoring and recommend that pharmacists collaborate with physicians in selecting appropriate patients and tailoring patient‐specific monitoring plans.
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