Kev ntsuam xyuas lub raum ua haujlwm thiab ncaj qha rau qhov ncauj Anticoagulants Dosing: Peb Puas Muaj Hnub Nyoog Tshiab?
Mar 09, 2022
Hauv qhov teeb meem ntawm Circulation: Cardiovascular Quality and Outcomes, Rohla et al1 tsa kev txhawj xeeb txog kev coj ua tam sim no ntawm kev ua haujlwmlub raumKev hloov kho tshuaj rau kev ua yeeb yam ntawm qhov ncauj ncaj qha (DOACs) hauv cov neeg mob atrial fibrillation (AF) ntawm kwv yees creatinine clearance (CrCl).1 Siv cov ntaub ntawv sau npe rau cov neeg mob AF, lawv kwv yees CrCl siv Cockcroft-Gault (CG) mis thiab glomerular Pom tus nqi (GFR) siv Kev Hloov Kho Kev Noj Qab Haus Huv hauvMob raumthiab ChronicKab mob raumEpidemiology Collaboration (CKD-EPI) cov qauv; lawv piv cov thromboembolic thiab los ntshav cov teeb meem ntawm cov neeg mob uas tsis sib xwslub raumdosing indications siv 3 cov qauv raws li cov lus qhia hauv Tebchaws Europe. Ze li ntawm 40 feem pua ntawm cov neeg mob yuav xav tau kev hloov kho ntau npaum li cas los ntawm Kev Hloov Kho Kev Noj Qab Haus Huv hauvMob raumlos yog CKD-EPI cov qauv siv CG. Qhov tseem ceeb, cov xwm txheej thromboembolic tau 5-fold siab dua hauv cov neeg mob uas nws cov koob tshuaj DOAC yuav tau hloov kho raws li kev faib tawm tshiab siv cov qauv CKD-EPI piv nrog cov qauv CG (4.1 feem pua vim 0.8 feem pua , P{ {7}}.01). Cov xwm txheej los ntshav tseem ceeb kuj muaj ntau dua nyob rau hauv cov neeg mob uas tau muab faib rov qab siv cov mis CKD-EPI (5.7 feem pua vim 2.7 feem pua, P=0.09), tab sis qhov sib txawv tsis yog qhov tseem ceeb.
Ntsiab lus:Cov ntawv sau; atrial; fibrillation; creatinine; glomerular pom tus nqi; warfarin; raum; lub raum
CISTANCHE yuav txhim kho rau lub raum/ raum mob
Tshaj li kaum xyoo dhau los, DOACs tau tshaj warfarin raws li qhov tseem ceeb ntawm qhov ncauj anticoagulant siv los tiv thaiv mob hlab ntsha tawg hauv cov neeg mob AF, suav txog 87 feem pua ntawm cov tshuaj tiv thaiv qhov ncauj rau qhov kev qhia no hauv kev tshuaj ntsuam tsis ntev los no.2 Ntawm cov neeg mob tau sau DOACs rau AF, qhov zaus ntawm CKD yog kwv yees li ntawm 11.5 feem pua thiab 44.6 feem pua .2 Qhov tseem ceeb, txhua qhov ntawm 4 DOACs tau pom zoo rau kev tiv thaiv kab mob stroke hauv AF yuav tsum tau hloov ntau npaum li cas hauv qhov chaw ntawm CKD.3–6 Rau 3 ntawm cov tshuaj no—dabigatran, rivaroxaban, thiab edoxaban—lub raumKev hloov kho koob tshuaj yog raws li kwv yees CrCl, feem ntau suav nrog CG formula.3,4,6,7 Keeb kwm luam tawm xyoo 1976, CG formula rau kwv yees CrCl yog tus qauv siv los ntsuas.lub raum ua haujlwmthiab qhia kev hloov kho tshuaj rau cov tshuaj uas tau tshem tawm tiag tiag, xws li DOACs.7 Siv cov ntaub ntawv kho mob thiab pej xeem uas muaj nyob hauv-hnub nyoog, poj niam txiv neej, qhov hnyav, thiab ntshav creatinine-cov qauv CG yog qhov yooj yim, suav tau yooj yim, feem ntau tshaj tawm hauv hluav taws xob noj qab haus huv. cov ntaub ntawv, thiab feem ntau muab tso rau hauv kev txiav txim siab ntawm cov txheej txheem kho mob kom ceeb toom cov kws kho mob txog qhov yuav tsum tau kho cov tshuaj noj vim qhov txo qislub raum ua haujlwm. Xyoo 1998, Lub Chaw Tswj Xyuas Khoom Noj thiab Tshuaj tau muab cov lus qhia rau kev lag luam kws tshuaj pom zoo kom siv cov tshuaj hloov kho rau cov neeg mob uas muajlub raumKev puas tsuaj raws li kev kwv yees ntawm CrCl, qhia txog cov qauv CG-tab sis tsis yog lwm tus-raws li ib txoj hauv kev los kwv yees CrCl.8Txawm li cas los xij, siv cov qauv CG los ntsuaslub raum ua haujlwmmuaj qee qhov pitfalls. Lwm txoj hauv kev rau kev kwv yeeslub raum ua haujlwmmuaj nyob thiab tej zaum yuav muaj tseeb dua nyob rau hauv kev kwv yees GFR.9,10 Tsis tas li ntawd, kev suav ntawm CrCl siv cov qauv CG tuaj yeem ua rau muaj kev cuam tshuam hauv qee qhov xwm txheej kho mob (xws li kev rog rog, kev suav tshuaj CG) uas ua rau tsis raug.lub raum ua haujlwmkev ntsuam xyuas thiab kev hloov kho tshuaj tsis raug. Nyob rau hauv rooj plaub ntawm DOACs, kev kho tshuaj tsis tsim nyog raws li kev kwv yees tsawg dua ntawm GFR tuaj yeem ua rau cov neeg mob muaj kev pheej hmoo rau cov teeb meem thromboembolic thiab los ntshav.
CISTANCHE yuav txhim kho lub raum / raum mob ntshav qab zib
Muab cov nuances txuam nroglub raumdosing cov lus pom zoo rau DOACs, nws tsis yog qhov xav tsis thoob tias Rohla li al pom kev siv lwm cov qauv los kwv yees GFR yuav ua rau muaj kev hloov kho ntau npaum li cas ntawm cov neeg mob. Txij li thaum creatinine excretion yog cuam tshuam los ntawm cov leeg nqaij, lub cev qhov hnyav, thiab qhov hnyav tuaj yeem cuam tshuam CrCl kwv yees suav nrog CG formula. Kev tshuaj xyuas cov ntaub ntawv hauv Tebchaws Meskas rau rivaroxaban qhia txog kev siv tag nrho lub cev qhov hnyav thaum kwv yees CrCl thaum siv tag nrho lub cev hnyav yog siv rau hauv cov ntaub ntawv sau rau edoxaban, uas qhia txog kev siv CG formula.4,6 Cockcroft thiab Gault7 lees paub. uas lub cev habitus (piv txwv li, cov leeg nqaij tsawg) thiab qhov hnyav hnyav (piv txwv li, pom kev rog) tuaj yeem ua rau qhov tsis raug kwv yees ntawm CrCl. Piv txwv li, hauv cov neeg mob rog rog, CrCl tuaj yeem kwv yees ntau dhau thaum siv tag nrho lub cev qhov hnyav hauv CG mis thiab qis dua thaum siv lub cev qhov hnyav, uas ua rau muaj kev hloov kho tshuaj tsis tsim nyog ntawm DOACs. Interestingly, Lucijanic et al11 pom muaj kev sib raug zoo ntawm lub cev qhov hnyav thiab ob qho tib si thromboembolic thiab los ntshav cov teeb meem hauv cov neeg mob kho nrog DOACs. Tsis muaj kev sib koom ua ke ntawm qhov kwv yees GFR, suav nrog Kev Hloov Kho Kev Noj Qab Haus Huv hauvMob raumcov mis uas tsis suav nrog qhov hnyav, thiab cov txiaj ntsig kho mob; Cov koom haum nrog CrCl tsis raug soj ntsuam.11 Hauv cov neeg mob hnyav, rog, thiab cov neeg mob rog rog, cov kev tshawb fawb tau qhia tias qhov kev kwv yees tseeb tshaj plaws ntawm CrCl yog tau los ntawm kev siv lean lossis hloov lub cev hnyav thaum siv CG formula.12,13 Txawm li cas los xij, ua li ntawd tsis sib haum xeeb. nrog rau kev sau cov ntaub ntawv rau rivaroxaban thiab edoxaban thiab tej zaum yuav ua rau kev noj tshuaj tsis xwm yeem. Rohla et al1 siv tag nrho lub cev hnyav hauv lawv qhov kev suav ntawm CrCl uas yuav overestimate CrCl nyob rau hauv cov neeg mob rog rog thiab rog thaum siv cov mis CG. Txawm hais tias lawv tsis tau tshaj tawm qhov hnyav, qhov ntsuas lub cev qhov hnyav (28.0± 4.8 kg / m2) yog qhov qhia txog cov neeg rog rog uas qhov hnyav ntawm lub cev hloov tau raug ntau dua.1
Hauv kev sib piv rau dabigatran, rivaroxaban, thiab edoxaban, kev hloov kho apixaban-dose tsis yog nyob ntawm qhov kwv yees CrCl tab sis yog kev sib xyaw ua ke ntawm hnub nyoog, qhov hnyav, thiab cov ntshav creatinine.5 Cov koob tshuaj apixaban yuav tsum raug txo thaum twg 2 ntawm cov hauv qab no tau ntsib. : hnub nyoog Ntau dua lossis sib npaug li 80 xyoo, tag nrho lub cev hnyav Tsawg dua lossis sib npaug li 60 kg, lossis cov ntshav creatinine Ntau dua lossis sib npaug li 1.5 mg / dL.5 Vim tias kev hloov kho apixaban-dose hauv Tebchaws Meskas tsis yog raws li kev kwv yees ntawm CrCl, nws yuav nyiam rau lwm cov DOACs hauv cov neeg mob uas qhov kev kwv yees ntawm CrCl yuav tsis raug, xws li qhov hnyav hnyav, kom txog rau thaum muaj kev pom zoo rau qhov zoo tshaj plaws-thiab qhov ua tau zoo- txoj kev coj DOAClub raumkev kho tshuaj noj.
CISTANCHE yuav txhim kho lub raum / raum mob
Saib rau pem hauv ntej, nws yuav yog lub sijhawm rov ntsuas dua siv cov qauv CG raws li tus qauv los kwv yees CrCl thiab qhialub raumdosing adjustments for DOACs.14 Muab hais tias Kev Hloov Kho Kev Noj Haus hauvMob raumthiab CKD-EPI cov qauv tau pom tias muaj kev kwv yees ntawm GFR ntau dua li cov qauv CG, cov kws tshawb fawb hauv ob lub zej zog kev kawm thiab kev lag luam tshuaj yuav tsum ntsuas seb puas siv lwm txoj hauv kev rau CG formula los kwv yees GFR thiab qhia.lub raumKev noj tshuaj ntawm DOACs txhim kho lawv cov tshuaj pharmacokinetics, pharmacodynamics, kev ua tau zoo, thiab kev nyab xeeb raws li kev soj ntsuam ntawm Rohla li al hais. Tsis tas li ntawd, yog tias qhov kev ntsuam xyuas no ua rau cov neeg mob tau txais txiaj ntsig zoo dua, Lub Chaw Tswj Xyuas Khoom Noj thiab Tshuaj yuav tsum xav txog kev hloov kho tshiab.lub raumKev pom zoo noj tshuaj rau DOACs suav nrog kev siv lwm cov qauv los kwv yees GFR.
Nws yog qhov ua tau, yog tias tsis zoo, uas ib qho-loj- haum-txhua txoj hauv kev los ntsuaslub raum ua haujlwmthiab ualub raumKev hloov kho tshuaj (piv txwv li, kev siv cov mis CG) tsis txaus - ob qho tib si rau DOACs thiab lwm yam tshuaj uas tau tshem tawm tiag tiag, tshwj xeeb tshaj yog cov uas muaj qhov nqaim kho qhov rai ntawm kev nyab xeeb thiab kev ua tau zoo. Muaj pov thawj hauv lwm qhov chaw (xws li platin-based chemotherapy, vancomycin, thiab lwm yam) uas siv kwv yees GFR (xam los ntawm lwm cov qauv) es tsis yog CrCl (xws li CG formula) tuaj yeem coj kev txiav txim siab kho mob, ua kom zoo dua noj, thiab kwv yees qhov tshwm sim tsis zoo. .14 Raws li nrog DOACs, cov kws tshawb fawb kev kawm, kev lag luam tshuaj, thiab Lub Chaw Tswj Xyuas Khoom Noj thiab Tshuaj yuav tsum tshuaj xyuas seb cov qauv no puas ua kom zoo dua cov tshuaj uas tau tshem tawm tiag tiag thiab muab tso rau hauvlub raumCov lus pom zoo noj tshuaj yog tias kev tshawb fawb pom zoo GFR-raws lilub raumdosing adjustments zoo ib yam li Rohla thiab piav qhia ntawm no hauv.1 Tom qab ntawd peb yuav tuaj yeem tig nplooj ntawv los ntawm CG formula.
Nyob rau hauv lub meantime, lub koom haum ntawm misclassification ntawmlub raumKev hloov kho koob tshuaj ntawm DOACs nrog kev pheej hmoo siab ntawm cov xwm txheej thromboembolic txhawb nqa qhov tseem ceeb ntawm kev ntsuam xyuaslub raum ua haujlwmthiab xav kom kho DOC koob tshuaj. Ib qho ntawm cov txiaj ntsig tseem ceeb ntawm DOACs yog lawv qhov kev xav tau tsawg zuj zus rau kev saib xyuas niaj hnub piv nrog kev saib xyuas hnyav ntawm International Normalized Ratio xav tau nrog warfarin. Txawm li cas los xij, kev ntsuam xyuas ntawmlub raum ua haujlwmnyob rau hauv lub hauv paus thiab tsis tu ncua nyob rau hauv lub chav kawm ntawm kev kho mob yog guaranteed. Kev siv cov chaw kho mob anticoagulation, feem ntau yog tswj hwm los ntawm cov kws kho mob uas tsis yog kws kho mob, los saib xyuaslub raum ua haujlwmntawm lub sijhawm tau txiav txim siab ua ntej thiab ua qhov tsim nyog hloov kho tau raug qhia.15 Muab cov xwm txheej ntawm COVID-19 kis thoob qhov txhia chaw, lub tswv yim ntawm cov chaw kho mob virtual anticoagulation (xws li, huab cua tiv thaiv coagulation) tuaj yeem ua rau peb ceev faj hauv kev saib xyuas.lub raum ua haujlwmthiab ua qhov tsim nyog hloov kho rau cov neeg mob kho nrog DOACs.15 Cov kws kho mob feem ntau yog ib feem ntawm pab pawg tshuaj tiv thaiv kab mob, nkag siab txog qhov teeb meem cuam tshuam nrog CG cov mis, thiab tuaj yeem muab pragmatic.lub raumCov lus pom zoo noj tshuaj rau DOACs thaum muaj qhov tsis paub tseeb tshwm sim.
