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🫀 Пероральные антикоагулянты у пациентов с ХБП и ФП/ВТЭ: новый метаанализ
🔥 Главное:
- У больных с ХБП и ФП ДОАК эффективнее варфарина в профилактике геморрагического инсульта (RR = 0.455; p = 0.002), а также снижают риск больших (RR = 0.604; p = 0.002) и внутримозговых кровотечений (RR = 0.424; p < 0.001).
- Для ВТЭ у пациентов с нарушением функции почек: сравнимые результаты по частоте рецидива и VTE-смертности между ДОАК и варфарином, а числа крупных кровотечений были сопоставимы (RR = 0.543; p = 0.208).
🧪 Контекст: метаанализ 15 РКИ (n = 16 361), пациенты с ХБП и ФП или ВТЭ, сравнение ДОАК и варфарина по эффективности и безопасности.
📍 Практическая польза:
- ДОАК предпочтительнее для большинства пациентов с ХБП и ФП благодаря более низкому риску геморрагического инсульта и крупных кровотечений, включая внутричерепные.
- При ВТЭ и ХБП — допускается применение как ДОАК, так и варфарина, выбор — индивидуализирован.
🔗 PubMed | DOI
❓ Какова оптимальная доза ДОАК для продленного лечения ВТЭ?
✅ Ответ: Уменьшенная доза ДОАК столь же эффективна, как и полная, при меньшем риске крупных или клинически значимых некрупных кровотечений (RR = 0.71; p < 0.0001). Результаты были стабильны в подгруппах с онкологией и на различных ДОАК.
🧪 Контекст: метаанализ 5 РКИ (n = 8 781), сравнивали полные и редуцированные дозы ДОАК (апиксабан/ривароксабан) при продлённой антикоагуляции пациентов с ВТЭ (в том числе с опухолями).
📍 Как применять:
- У пациентов с высоким риском кровотечений или требующих длительной антикоагуляции после ВТЭ — рассмотрите редуцированную дозу ДОАК.
- Особо актуально для пожилых и пациентов с сопутствующей патологией (включая онкологию).
🔗 PubMed | DOI
🧠 Безопасность ДОАК vs НМГ у пациентов с опухолями мозга
🔥 Главное:
- ДОАК ассоциированы со значительно меньшим риском ВЧК, чем низкомолекулярные гепарины (RR = 0.50; p = 0.01), особенно при первичных опухолях мозга (RR = 0.20; p < 0.01).
🧪 Контекст: метаанализ 10 ретроспективных когортных исследований (n = 1 572: 645 на ДОАК, 895 на НМГ), пациенты с первичными/метастатическими опухолями мозга, антикоагулянтная терапия.
📍 Практическая польза:
- Для артериального/венозного тромбоза у больных с опухолями мозга ДОАК могут быть безопаснее по риску ВЧК, особенно при первичных опухолях.
- Индивидуализируйте выбор антикоагулянта с учетом типа опухоли и риска кровотечений.
🔗 PubMed | DOI
1. Accelerated Apixaban Removal by Using the ADVanced Organ Support (ADVOS) Albumin Hemodialysis System-A Case Report.
Intervention
Postoperative use of the ADVanced Organ Support (ADVOS) albumin hemodialysis system
title
Accelerated Apixaban Removal by Using the ADVanced Organ Support (ADVOS) Albumin Hemodialysis System-A Case Report
journal
The Thoracic and Cardiovascular Surgeon Reports
date
2024-07-01
doi
10.1055/a-2682-8640
pmid
40959463
abstract
In patients on direct oral anticoagulants (DOAC), emergency surgery is characterized by the occurrence of a massively increased tendency to bleed. Currently, there is no approved antidote for postoperative patients, making specific therapy challenging in these situations. Emergency surgery was required for a 72-year-old male patient who was in cardiogenic shock due to severe aortic regurgitation resulting from acute prosthetic valve endocarditis. Due to atrial fibrillation, the patient was on apixaban, a factor Xa (FXa) inhibitor anticoagulant, until surgery. We used the ADVanced Organ Support (ADVOS) albumin hemodialysis system postoperatively to treat persisting shock with multi-organ failure, acidosis, and DOAC removal. Serial drug-level measurements revealed strongly accelerated apixaban clearance. In line with this, we observed only moderate drainage losses. ADVOS accelerates the removal of apixaban and is a promising therapy for preventing bleeding complications in patients receiving DOAC therapy after emergency surgery.
authors
[]
patient
{'age': 72, 'sex': 'male', 'medical_conditions': ['cardiogenic shock', 'severe aortic regurgitation', 'acute prosthetic valve endocarditis', 'atrial fibrillation', 'multi-organ failure', 'acidosis'], 'medications': [{'name': 'apixaban', 'indication': 'anticoagulation for atrial fibrillation'}]}
outcomes
['Accelerated apixaban clearance', 'Moderate drainage losses', 'Potential reduction of bleeding complications']
conclusion
ADVOS may be a promising therapy for accelerating removal of apixaban and preventing bleeding complications in patients on DOAC therapy following emergency surgery.
Journal: The Thoracic and cardiovascular surgeon reports
Impact Factor: —
Date: 2024/7/1
PMID: 40959463
DOI: 10.1055/a-2682-8640
2. Efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants for extended treatment of venous thromboembolism: A meta-analysis with trial sequential analysis and reconstructed time-to-event data.
title
Efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants for extended treatment of venous thromboembolism: A meta-analysis with trial sequential analysis and reconstructed time-to-event data
journal
Thrombosis Research
publication_date
2025-06-25
impact_factor
5.05
quartile
Q1
doi
10.1016/j.thromres.2025.109476
pmid
40957133
crd_number
CRD420251048675
objective
Evaluate the efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants (DOACs) for extended venous thromboembolism (VTE) treatment.
background
Optimal dosing strategy for extended anticoagulation in VTE, particularly in cancer-associated VTE, remains uncertain.
methods
{'data_sources': 'Major electronic databases through April 2025', 'study_selection': 'Randomized controlled trials (RCTs) comparing reduced-dose versus full-dose DOACs for VTE treatment', 'number_of_studies': 5, 'total_patients': 8781, 'outcomes': ['Recurrent VTE prevention', 'Major or clinically relevant non-major bleeding', 'All-cause mortality'], 'effect_measures': ['Risk Ratio (RR)', 'Hazard Ratio (HR)', '95% Confidence Intervals (CI)'], 'analysis': ['Random-effects models', 'Reconstructed time-to-event data from Kaplan-Meier curves', 'Trial sequential analysis (TSA)']}
results
{'recurrent_vte': {'rr': 0.94, 'ci': '0.68-1.29', 'p_value': 0.7, 'hr': 0.89, 'hr_ci': '0.78-1.02', 'hr_p_value': 0.1}, 'major_or_crnm_bleeding': {'rr': 0.71, 'ci': '0.61-0.82', 'p_value': '<0.0001', 'hr': 0.61, 'hr_ci': '0.57-0.66', 'hr_p_value': '<0.001'}, 'all_cause_mortality': 'No differences observed', 'subgroup_analyses': 'Consistent results in patients with and without active cancer, and across different DOACs (apixaban, rivaroxaban)', 'tsa': 'Sufficient evidence for efficacy and safety'}
conclusions
Reduced-dose DOACs are as effective as full-dose regimens in preventing recurrent VTE, but offer a better safety profile. They may be preferred for extended anticoagulation, especially in patients at high risk of recurrence.
Journal: Thrombosis research
Impact Factor: 5.05
Date: 2025/6/25
PMID: 40957133
DOI: 10.1016/j.thromres.2025.109476
3. Intracranial Hemorrhage With Direct Oral Anticoagulants vs Low-Molecular-Weight Heparin in Brain Tumors: A Review and Meta-Analysis.
title
Intracranial Hemorrhage With Direct Oral Anticoagulants vs Low-Molecular-Weight Heparin in Brain Tumors: A Review and Meta-Analysis
journal
Neurology
publication_date
2025-09-16
impact_factor
4.57
quartile
Q1
doi
10.1212/WNL.0000000000214140
pmid
40953341
prospero_registration
CRD42025635334
study_type
Meta-analysis of retrospective cohort studies
data_sources
['MEDLINE', 'Embase', 'Web of Science', 'Cochrane Central Register of Controlled Trials']
search_period
January 2010-June 2025
population
{'age': '≥18 years', 'diagnosis': 'Primary or metastatic brain tumors', 'interventions': ['DOACs (apixaban, rivaroxaban, edoxaban, betrixaban, dabigatran)', 'LMWH (enoxaparin, dalteparin, nadroparin, tinzaparin)']}
exclusion_criteria
['Studies limited to prophylactic dosing', 'Studies with non-brain tumor patients']
included_studies
10
total_patients
1572
group_numbers
{'DOAC': 645, 'LMWH': 895}
age_range
{'DOAC': '60.4-67 years', 'LMWH': '53-64 years'}
follow_up_duration_months
3-12
primary_outcome
Intracranial hemorrhage (ICH)
main_results
{'any_ICH': {'RR': 0.5, 'CI_95': '0.29-0.87', 'p_value': 0.01, 'I2': 49.5}, 'three_month_followup': {'studies': 3, 'RR': 0.23, 'CI_95': '0.09-0.57', 'p_value': '<0.01', 'I2': '<0.01'}, 'primary_brain_tumors': {'studies': 5, 'RR': 0.2, 'CI_95': '0.08-0.54', 'p_value': '<0.01', 'I2': '<0.01'}, 'metastatic_brain_tumors': {'studies': 5, 'RR': 0.86, 'CI_95': '0.44-1.68', 'p_value': 0.66, 'I2': 36.04}}
heterogeneity
{'any_ICH': 49.5, 'three_month_followup': '<0.01', 'primary_brain_tumors': '<0.01', 'metastatic_brain_tumors': 36.04}
robustness_assessment
Leave-one-out and cumulative meta-analysis confirmed robustness and stable estimates
publication_bias
{'egger_p_value': 0.19, 'begg_p_value': 0.59}
conclusion
DOACs are associated with significantly lower risk of intracranial hemorrhage compared to LMWH in patients with brain tumors, especially in primary brain tumors, supporting DOACs as a safe anticoagulant option. However, observational study designs warrant cautious interpretation due to potential confounding.
Journal: Neurology
Impact Factor: 4.57
Date: 2025/9/16
PMID: 40953341
DOI: 10.1212/WNL.0000000000214140
4. Efficacy and safety of oral anticoagulants in the treatment of chronic kidney disease with atrial fibrillation or venous thromboembolism: a systematic review and meta-analysis.
title
Efficacy and safety of oral anticoagulants in the treatment of chronic kidney disease with atrial fibrillation or venous thromboembolism: a systematic review and meta-analysis
journal
Frontiers in Pharmacology
publication_date
2025-04-21
impact_factor
5.35
quartile
Q1
doi
10.3389/fphar.2025.1615284
pmid
40949128
clinicaltrials_gov_identifier
CRD42024510727
objective
To compare the efficacy and safety of warfarin and direct oral anticoagulants (DOACs) in the treatment of chronic kidney disease (CKD) with atrial fibrillation (AF) or venous thromboembolism (VTE).
methods
{'databases_searched': ['PubMed', 'Embase', 'Web of Science', 'Cochrane Library', 'ClinicalTrials.gov'], 'search_end_date': '2024-06-30', 'inclusion_criteria': 'Randomized controlled trials (RCTs) assessing the efficacy and safety of warfarin and DOACs in CKD patients with AF or VTE', 'outcomes': {'CKD_VTE_patients': ['thrombosis recurrence or VTE-related deaths', 'major bleeding'], 'CKD_AF_patients': ['stroke or systemic embolism', 'major bleeding']}, 'risk_of_bias_tool': "Cochrane Collaboration's tool"}
results
{'number_of_studies': 15, 'total_participants': 16361, 'doacs_vs_warfarin_af_ckd': {'hemorrhagic_stroke': {'effect': 'reduced', 'risk_ratio': 0.455, '95%_CI': [0.275, 0.752], 'p_value': 0.002}, 'ischemic_stroke': {'effect': 'no significant difference'}, 'major_bleeding': {'effect': 'reduced', 'risk_ratio': 0.604, '95%_CI': [0.442, 0.825], 'p_value': 0.002}, 'intracranial_bleeding': {'effect': 'reduced', 'risk_ratio': 0.424, '95%_CI': [0.287, 0.626], 'p_value': '<0.001'}}, 'doacs_vs_warfarin_vte_ckd': {'vte_recurrence_or_death': {'effect': 'no significant difference', 'risk_ratio': 0.663, '95%_CI': [0.409, 1.073], 'p_value': 0.094}, 'major_bleeding': {'effect': 'no significant difference', 'risk_ratio': 0.543, '95%_CI': [0.209, 1.407], 'p_value': 0.208}}}
conclusions
{'af_ckd': 'DOACs demonstrate superior efficacy and safety compared to warfarin in CKD patients with atrial fibrillation.', 'vte_ckd': 'DOACs exhibit comparable efficacy and safety to warfarin in CKD patients with venous thromboembolism.'}
Journal: Frontiers in pharmacology
Impact Factor: 5.35
Date: 2025/4/21
PMID: 40949128
DOI: 10.3389/fphar.2025.1615284