Manual práctico de Trombosis y Hemostasia de la SETH

— 1 6 6 — I I . PA T O LO G Í A D E L A H E M O ST A S I A Dabigatran posee un agente reversor, el idarucizumab, un anticuerpo específico. La administración de 5 g iv (2 dosis con- secutivas de 2,5 g) consiguen revertir total y mantenidamente el efecto anticoagulante de dabigatran. Rivaroxaban, apixaban y edoxaban no disponen en la ac- tualidad de ningún agente reversor. Andexanet, una molécula análoga al F-Xa sin actividad procoagulante, ha demostrado ser capaz de revertir el efecto de los ACOD anti-Xa de forma transitoria (deberá ser administrado como bolo seguido de infusión continua). Por el momento no tiene el uso aprobado. La administración de concentrado de complejo protrom- bínico se contempla en pacientes tratados con ACOD anti-Xa con necesidad urgente de reversión, aunque carece de eviden- cia de calidad sobre que esta sea una estrategia eficaz y segura. BIBLIOGRAFÍA 1. Schulman S, Beyth RJ, Kearon C, Levine MN. Hemorrhagic Com- plications of Anticoagulant and Thrombolytic Treatment: Ameri- can College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 8 th ed. Chest 2008;133:257-98. 2. Fang MC, Go AS, ChangY, Hylek EM, Henault LE, Jensvold NG, et al. Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med 2007;120:700-5. 3. Klok FA, Kooiman J, Huisman MV, Konstantinides S, Lankeit M. Predicting anticoagulant-related bleeding in patients with ve- nous thromboembolism: a clinically oriented review. Eur Respir J 2015;45:201-10. 4. Torn M, Cannegieter SC, Bollen WL, van der Meer FJ, van der Wall EE, Rosendaal FR. Optimal level of oral anticoagulant the- rapy for the prevention of arterial thrombosis in patients with mechanical heart valve prostheses, atrial fibrillation, or myocardial infarction: a prospective study of 4202 patients. Arch Intern Med 2009;69:1203-9. 5. Rosendaal FR, Cannegieter SC, van der Meer FJ, Briët E. A me- thod to determine the optimal intensity of oral anticoagulant therapy.Thromb Haemost 1993;69:236-9. 6. Gallagher AM, Setakis E, Plumb JM, Clemens A, van Staa TP. Risks of stroke and mortality associated with suboptimal anticoagulation in atrial fibrillation patients.Thromb Haemost 2011;106: 968-77. 7. van Walraven C, Jennings A, Oake N, Fergusson D, Forster AJ. Effect of study setting on anticoagulation control: a systematic review and metaregression. Chest 2006;129:1155-66. 8. Heneghan C, Alonso-Coello P, García-Alamino JM, Perera R, Meats E, Glasziou P. Self-monitoring of oral anticoagulation: a sys- tematic review and meta-analysis. Lancet 2006;367:404-11. 9. Mueck W, Lensing AW, Agnelli G, Decousus H, Prandoni P, Mis- selwitz F Clin. Rivaroxaban: population pharmacokinetic analyses in patients treated for acute deep-vein thrombosis and exposure simulations in patients with atrial fibrillation treated for stroke prevention. Pharmacokinet 2011;50:675-86. 10. Heidbuchel H,Verhamme P,Alings M,Antz M,Diener HC,HackeW, et al. Updated European Heart RhythmAssociation Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-507. 11. Di Minno A, Frigerio B, Spadarella G, Ravani A, Sansaro D, Amato M, et al. Old and new oral anticoagulants: Food, herbal medicines and drug interactions. Blood Rev 2017;31:193-203. 12. Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014;383:955-62. 13. Samuelson BT, Cuker A, Siegal DM, Crowther M, García DA. La- boratory Assessment of the Anticoagulant Activity of Direct Oral Anticoagulants: A Systematic Review. Chest 2017;151:127-38. Tabla XV Última toma del ACOD antes de la cirugía electiva (10) FG (ml/min) Dabigatran Apixaban, edoxaban, rivaroxaban Riesgo de sangrado quirúrgico Bajo Elevado Bajo Elevado � 80 � 24 h � 48 h � 24 h � 48 h 50-80 � 36 h � 72 h (3 d) � 24 h � 48 h 30-50 � 48 h � 96 h (4 d) � 24 h � 48 h 15-30 No indicado � 36 h � 48 h < 15 No indicado FG: filtrado glomerular.