Желудочно-кишечные кровотечения при использовании новых пероральных антикоагулянтов: эпидемиология, факторы риска, лечение и профилактика

Новые пероральные антикоагулянты (НОАК) – прямой ингибитор тромбина дабигатран, селективные ингибиторы фактора Xa ривароксабан и апиксабан – все шире используются в реальной клинической практике как эффективное антитромботическое средство. К сожалению, эти препараты могут вызывать серьезные неблагоприятные реакции, среди которых одним из наиболее частых является желудочно-кишечное кровотечение. Это осложнение ежегодно развивается у 2–3% больных, принимающих НОАК. Источники кровотечения могут находиться как в верхних, так и в нижних отделах желудочно-кишечного тракта (ЖКТ). Нередко причиной кровотечения становятся недиагностированные новообразования ЖКТ, чаще – колоректальный рак. Согласно данным клинических и когортных исследований, наибольший риск кровотечений отмечается при использовании ривароксабана. Факторами риска являются пожилой возраст, сопутствующий прием нестероидных противовоспалительных препаратов, аспирина, других антикоагулянтов, патология ЖКТ, инфекция H. pylori, нарушение функции почек и печени, прием алкоголя. Лечение желудочно-кишечного кровотечения осуществляется по общим принципам, с использованием эндоскопических и хирургических методов. Особое значение придается блокаде антикоагулянтного действия НОАК. В последнее время с этой целью была разработана и проходит клиническую апробацию целая серия «антидотов» – идаруцизумаб (он уже применяется в ряде стран мира), андексанет и цирапарантаг. Профилактика кровотечений заключается в контроле факторов риска, рациональном использовании НОАК, профилактическом назначении ингибиторов протонной помпы, своевременном прерывании приема антикоагулянтов перед травматичными медицинскими манипуляциями на органах ЖКТ (в частности, перед определенными эндоскопич скими процедурами).

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