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🫀 Доказательства в пользу ДОАК у пациентов с ФП и ХБП: новые данные метаанализа
🔥 Главное в 3 пунктах
• ДОАК значительно снижают риск внутримозгового кровоизлияния у пациентов с ФП и ХБП по сравнению с варфарином (RR=0,424, 95% ДИ: 0,287–0,626, p<0,001).
• Риск крупных кровотечений также ниже на ДОАК (RR=0,604, 95% ДИ: 0,442–0,825, p=0,002).
• Эффективность в предотвращении рецидива ВТЭ или смерти схожа для ДОАК и варфарина у пациентов с ВТЭ и ХБП.
🧪 Контекст: 15 РКИ, 16 361 пациент с ХБП и ФП или ВТЭ, анализируемая эффективность и безопасность пероральных антикоагулянтов (ДОАК и варфарин).
📍Практическая польза: Для стратификации риска кровотечений и инсульта у пациентов с ФП и сопутствующей ХБП стоит отдавать предпочтение ДОАК (в т.ч. апиксабану) перед варфарином. Для ВТЭ на фоне ХБП — антикоагулянты сопоставимы по эффективности и безопасности.
🔗 PubMed | DOI
🧪 Продлённая терапия ВТЭ: метаанализ доз ДОАК
🫀 Что изучали: эффективность и безопасность применения сниженной по сравнению с полной дозой ДОАК для продлённого лечения ВТЭ (5 РКИ, 8781 пациент, дозировки апиксабана и ривароксабана).
📈 Ключевые результаты:
— Эффективность в профилактике рецидива ВТЭ сопоставима у сниженной и полной доз ДОАК (HR 0,89; 95% ДИ 0,78–1,02; p=0,10).
— Сниженная доза обеспечивает существенно меньший риск крупных/клинически значимых некрупных кровотечений (HR 0,61; 95% ДИ 0,57–0,66; p<0,001), независимо от типа препарата и наличия онкозаболевания.
📍 Что это меняет на практике: Для пациентов, которым требуется продлённая антикоагуляция после ВТЭ и есть опасения по риску кровотечений — сниженная доза ДОАК обеспечивает безопасный компромисс без потери эффективности.
🔗 PubMed | DOI
📊 Антикоагуляция у онкопациентов с опухолями мозга: риск ВЧК ниже на ДОАК
❓ Вопрос практики: Какой антикоагулянт предпочтительнее для пациентов с опухолями мозга, которым требуется терапия по поводу ТЭО?
✅ Ответ исследования: Метаанализ (10 ретроспективных когорт, 1572 пациента) показал, что у пациентов с первичными опухолями мозга риск внутричерепного кровоизлияния на ДОАК был ниже в 5 раз по сравнению с НМГ (RR=0,20; 95% ДИ 0,08–0,54; p<0,01); в группе метастатических опухолей различий не отмечено.
📍 Как применить: Для пациентов с первичными опухолями мозга, нуждающихся в антикоагуляции, ДОАК являются безопасным выбором. Для пациентов с метастатическим поражением — осторожная индивидуализация схемы.
🔗 PubMed | DOI
1. A Sole Case of Concurrent Arterial and Venous Thromboses with Massive Pulmonary Embolism and Carriage of Four Genetic Polymorphisms: Factor V Leiden, PAI-1 4G/5G, MTHFR C677T, and ACE I/D-A Case Report.
title
A Sole Case of Concurrent Arterial and Venous Thromboses with Massive Pulmonary Embolism and Carriage of Four Genetic Polymorphisms: Factor V Leiden, PAI-1 4G/5G, MTHFR C677T, and ACE I/D-A Case Report
journal
Reports (MDPI)
publication_date
2025-09-22
doi
10.3390/reports8030167
pmid
40981125
abstract
{'background_and_significance': 'Arterial and venous thromboses are usually separate entities with distinct mechanisms. Concurrent presentation with massive pulmonary embolism (PE) is extremely rare and carries diagnostic/therapeutic challenges.', 'case_presentation': {'age': 61, 'sex': 'male', 'comorbidities': ['well-controlled hypertension', 'type 2 diabetes'], 'thrombotic_events': ['deep vein thrombosis (DVT) of right popliteal vein', 'arterial thrombosis of left iliac artery', 'massive pulmonary embolism'], 'initial_treatment': ['conservative management per ESC 2019 Guidelines', 'unfractionated heparin (UFH)', 'low-molecular-weight heparin', 'direct oral anticoagulant (DOAC)', 'adjunctive therapy'], 'reason_for_surgical_intervention': 'Failed percutaneous revascularization and persistent arterial occlusion led to surgical thromboendarterectomy (TEA).', 'provoking_factors_absent': ['trauma', 'surgery', 'malignancy', 'antiphospholipid syndrome'], 'genetic_testing_indication': 'Atypical and severe presentation without classical causes prompted thrombophilia testing.'}, 'genetic_findings': [{'gene': 'Factor V Leiden (FVL)', 'genotype': 'heterozygous (R506Q)'}, {'gene': 'PAI-1', 'genotype': '4G/5G'}, {'gene': 'MTHFR', 'genotype': 'c.677C>T'}, {'gene': 'ACE I/D', 'genotype': 'homozygous DD'}], 'conclusions': 'The co-occurrence of these four thrombophilia-associated polymorphisms in a patient with simultaneous arterial and venous thromboses and massive PE is previously unreported. The case suggests gene-gene interactions may amplify thrombotic risk even when individual variants are of modest to moderate impact. A multidisciplinary approach is needed, and the findings highlight the importance of pharmacogenetics and cumulative genetic risk research in complex thrombotic phenotypes.'}
Journal: Reports (MDPI)
Impact Factor: —
Date: 2025/9/22
PMID: 40981125
DOI: 10.3390/reports8030167
2. Accelerated Apixaban Removal by Using the ADVanced Organ Support (ADVOS) Albumin Hemodialysis System-A Case Report.
Intervention
Postoperative ADVOS albumin hemodialysis
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.
keywords
['apixaban', 'direct oral anticoagulant', 'ADVOS', 'albumin hemodialysis', 'emergency surgery', 'bleeding complications', 'multi-organ failure']
main_findings
The ADVOS albumin hemodialysis system significantly accelerated apixaban clearance in a postoperative patient with multi-organ failure, suggesting it as a promising option for managing bleeding risks associated with DOACs after emergency surgery.
study_type
Case report
patient_info
{'age': 72, 'sex': 'male', 'condition': ['acute prosthetic valve endocarditis', 'severe aortic regurgitation', 'cardiogenic shock', 'multi-organ failure'], 'comorbidities': ['atrial fibrillation'], 'anticoagulant': 'apixaban'}
outcome
['accelerated apixaban clearance', 'moderate drainage losses', 'potential reduction of postoperative bleeding risk']
Journal: The Thoracic and cardiovascular surgeon reports
Impact Factor: —
Date: 2024/7/1
PMID: 40959463
DOI: 10.1055/a-2682-8640
3. 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
prospero_registration
CRD420251048675
study_type
Meta-analysis with trial sequential analysis
objective
To evaluate the efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants (DOACs) for extended treatment of venous thromboembolism (VTE), including cancer-associated VTE.
methods
{'databases_searched': 'Major electronic databases', 'last_search_date': 'April 2025', 'inclusion_criteria': 'Randomized controlled trials comparing reduced-dose vs. full-dose DOACs for VTE', 'number_of_rcts': 5, 'total_patients': 8781, 'statistical_methods': ['Random-effects model for pooled risk ratios and confidence intervals', 'Reconstructed time-to-event data from Kaplan-Meier curves', 'Trial sequential analysis (TSA) for conclusiveness']}
results
{'efficacy': {'recurrent_vte': {'risk_ratio': 0.94, 'ci_95': '0.68-1.29', 'p_value': 0.7, 'hazard_ratio': 0.89, 'hr_ci_95': '0.78-1.02', 'hr_p_value': 0.1}}, 'safety': {'major_or_clinically_relevant_non_major_bleeding': {'risk_ratio': 0.71, 'ci_95': '0.61-0.82', 'p_value': '<0.0001', 'hazard_ratio': 0.61, 'hr_ci_95': '0.57-0.66', 'hr_p_value': '<0.001'}}, 'subgroup_analyses': ['Consistent results in patients with and without active cancer', 'Consistent results across DOAC types: apixaban and rivaroxaban'], 'all_cause_mortality': 'No significant differences observed', 'tsa': 'Sufficient evidence for both efficacy and safety outcomes'}
conclusions
Reduced-dose DOACs are as effective as full-dose regimens in preventing recurrent VTE and have a better safety profile, supporting their preference for extended anticoagulation, particularly 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
4. 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_id
CRD42025635334
objective
Evaluate the safety of direct oral anticoagulants (DOACs) versus low-molecular-weight heparin (LMWH) on the development of intracranial hemorrhage (ICH) in patients with brain tumors.
methods
{'databases_searched': ['MEDLINE', 'Embase', 'Web of Science', 'Cochrane Central Register of Controlled Trials'], 'search_period': 'January 2010 to June 2025', 'study_types_included': ['Randomized-controlled trials', 'Cohort studies'], 'population': 'Adults (age ≥18 years) with primary or metastatic brain tumors receiving therapeutic DOACs vs LMWH', 'drugs_DOAC': ['apixaban', 'rivaroxaban', 'edoxaban', 'betrixaban', 'dabigatran'], 'drugs_LMWH': ['enoxaparin', 'dalteparin', 'nadroparin', 'tinzaparin'], 'exclusions': ['Studies limited to prophylactic dosing', 'Studies limited to non-brain tumor patients'], 'outcome_measured': 'Risk of any intracranial hemorrhage (ICH)', 'statistical_analysis': 'Pooled risk ratios (RRs) with 95% CIs using a restricted random-effects model; heterogeneity and publication bias assessed'}
results
{'studies_included': 10, 'study_type': 'Retrospective cohort', 'total_patients': 1572, 'patients_DOAC': 645, 'patients_LMWH': 895, 'age_DOAC': 'mean/median 60.4-67 years', 'age_LMWH': 'mean/median 53-64 years', 'followup_durations_months': '3-12', 'primary_findings': {'all_brain_tumors': {'RR': 0.5, 'CI_95': '0.29-0.87', 'p_value': 0.01, 'I2': 49.5}, 'three_months_followup': {'RR': 0.23, 'CI_95': '0.09-0.57', 'p_value': '<0.01', 'I2': '<0.01'}, 'primary_brain_tumors': {'RR': 0.2, 'CI_95': '0.08-0.54', 'p_value': '<0.01', 'I2': '<0.01'}, 'metastatic_brain_tumors': {'RR': 0.86, 'CI_95': '0.44-1.68', 'p_value': 0.66, 'I2': 36.04}}, 'robustness': 'Leave-one-out analyses confirmed results; cumulative meta-analysis showed stable estimates with narrowing CIs', 'publication_bias': {'egger_p': 0.19, 'begg_p': 0.59}}
conclusion
DOACs are associated with a significantly lower risk of intracranial hemorrhage compared to LMWH in anticoagulated brain tumor patients, especially in primary brain tumors. This suggests DOACs are a safe anticoagulant choice in this context, though findings should be interpreted cautiously due to observational study designs.
Journal: Neurology
Impact Factor: 4.57
Date: 2025/9/16
PMID: 40953341
DOI: 10.1212/WNL.0000000000214140
5. 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
clinical_trials_id
CRD42024510727
objectives
To compare the efficacy and safety of warfarin versus direct oral anticoagulants (DOACs) in treating chronic kidney disease (CKD) patients with atrial fibrillation (AF) or venous thromboembolism (VTE).
methods
{'study_design': 'Systematic review and meta-analysis of randomized controlled trials (RCTs)', 'databases_searched': ['PubMed', 'Embase', 'Web of Science', 'Cochrane Library', 'ClinicalTrials.gov'], 'search_end_date': '2024-06-30', 'inclusion_criteria': 'RCTs addressing efficacy and safety of warfarin and DOACs in CKD with AF or VTE', 'outcomes': {'VTE_patients': ['thrombosis recurrence or VTE-related deaths', 'major bleeding'], 'AF_patients': ['stroke or systemic embolism', 'major bleeding']}, 'risk_of_bias_tool': "Cochrane Collaboration's tool"}
results
{'studies_included': 15, 'participants': 16361, 'findings': {'AF_and_CKD': {'hemorrhagic_stroke': {'doacs_vs_warfarin': 'Reduced risk', 'RR': 0.455, 'CI': '0.275-0.752', 'P_value': 0.002}, 'ischemic_stroke': {'doacs_vs_warfarin': 'No significant difference'}, 'major_bleeding': {'doacs_vs_warfarin': 'Reduced risk', 'RR': 0.604, 'CI': '0.442-0.825', 'P_value': 0.002}, 'intracranial_bleeding': {'doacs_vs_warfarin': 'Reduced risk', 'RR': 0.424, 'CI': '0.287-0.626', 'P_value': '<0.001'}}, 'VTE_and_CKD': {'recurrent_vte_or_vte_related_deaths': {'doacs_vs_warfarin': 'No significant difference', 'RR': 0.663, 'CI': '0.409-1.073', 'P_value': 0.094}, 'major_bleeding': {'doacs_vs_warfarin': 'No significant difference', 'RR': 0.543, 'CI': '0.209-1.407', 'P_value': 0.208}}}}
conclusions
DOACs show superior efficacy and safety over warfarin in AF and CKD; in VTE and CKD, DOACs are comparable to warfarin in efficacy and safety.
url
http://www.clinicaltrials.gov
Journal: Frontiers in pharmacology
Impact Factor: 5.35
Date: 2025/4/21
PMID: 40949128
DOI: 10.3389/fphar.2025.1615284