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AD-COR Program inovativ de formare in domeniul cardiologiei pediatricePOSDRU/179/3.2/S/152012
MODUL TEORETIC
Tratamentul anticoagulantsi antiagregant la copil (2)
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Anticoagulare-definitie-
• Interventia terapeutica in mecanismul coagularii(“subtierea sangelui”) , astfel incat sa prevenim sausa tratam tromboza sau embolismul
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Tratamentul anticoagulant oral• Nu este tratament de faza acuta
• ACENOCUMAROL
(SINTROM, TROMBOSTOP)
• WARFARINA
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Indicatiile tratamentului anticoagulant oral(1)
• Tratamentul si preventia pe termen lung a trombozeivenoase profunde/ trombembolismului
pulmonar
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Indicatiile tratamentului anticoagulant oral(2)
• Proteze valvulare
• Fibrilatie atriala/flutter atrial
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Indicatiile tratamentului anticoagulant oral (3)
• Cardiomiopatii dilatative cu disfunctii sistolicesevere
• Trombi intracardiaci
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Indicatiile tratamentului anticoagulant oral(4)
• Dupa procedura chirurgicala Fontan (cord univentricular)
• In boala Kawasaki cu anevrisme coronariene
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Indicatiile tratamentului anticoagulant (5)
• In AVC ischemice
- in cazuri selectate – terapie cronica dupaAVC (eventual asociat cu antiagregant – aspirina)
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Indicatiile tratamentului anticoagulant (6)
• In cazul trombozelor venoase/emboliilor arteriale cuorice localizare (ex.tromboza vena renala, trombozaaorta, tromboza artere iliace, etc)
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Medicatia anticoagulanta orala
• Acenocumarol (Sintrom/ Trombostop)
• Warfarina (cumadin)
• Impiedica formarea factorilor de coagulare a caror sintezadepinde de vitamina K
• SE INITIAZA UZUAL IN PARALEL CU HEPARINA in cazultrombozelor acute care necesita anticoagulare pe termen lung(suprapunere aprox.5 zile)
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Warfarin
Synthesis of Non Functional
Coagulation Factors
Antagonismof
Vitamin K
Mecanismul de actiune al ACO
Vitamin K
VII
IX
X
II
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Protocolul de anticoagulare cu ACOINR Doza
Day 1 1.0-1.3 0.2 mg/kg orally
Days 2-4 1.1 –1.3 Repeat day 1 loading dose
1.4 –1.9 75% of day 1 loading dose
2.0 –3.0 50% of day 1 loading dose
3.1 –3.5 25% of day 1 loading dose
>3.5 Hold dosing until INR is <3.5
then restart according to stage
III guidelines
Maintenance
1.1 –1.4 Increase by 20% of dose
1.5 –1.9 Increase by 10% of dose
2.0–3.0 No change
3.1 –3.5 Decrease by 10% of dose
>3.5 Hold dosing until INR is <3.5 then restart at 20% less than last dose
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Supradozajul cu ACO
INR<5 Fara sangerari semnificative
Stop ACOINR seriate
INR=5-9Fara sangerari semnificative
Stop ACOVit.K oral daca este risc crescut de sangerare
INR>9Fara sangerari semnificative
Stop ACOVitamina K oral
INR>20 sau sangerari semnificative PPC 10-15 ml/kgVit.K 10 mg iv lent
INR crescut + hemoragii severe PPC 10-15 ml/kgFactor VII recombinatVit.K iv lent
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Heparina versus Warfarina
Heparina Warfarina
Mecanism de actiune Anti- factor II/X Inhiba sinteza factorilor II,VII,IX, X
Administrare i.v./s.c. Per os
Debut actiune Rapid (minute) Lent (ore)
Durata actiune Scurta (ore) Lunga (zile)
Monitorizare APTT INR
Antidot in caz de supradozaj Protamina Vitamina K
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Risc crescut de sangeraresub ACO (1)
• Traumatisme recente
• HTA necontrolata
• Trombocitopenie
• Deficit de factori de coagulare
• Insuficienta hepatica sau renala
• AVC
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Risc crescut de sangeraresub ACO (2)
• Deficite cognitive (pacienti/apartinatori responsabilide tratament)
• Istoric de caderi
• Ulcer gastro-duodenal
• Istoric de sangerari gastrointestinale/genito-urinare
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Sfaturi pentru pacientii aflati in tratamentcu ACO (1)
• Pastrati un calendar cu tratamentul cu ACO
• Raportati medicului orice
sangerare aparuta
• Cunoasteti doza actuala,
ultimul INR si momentul
urmatoarei recoltari
• Comunicati oricarui medic la care va prezentati casunteti in tratament cu ACO
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Sfaturi pentru pacientii aflati in tratamentcu ACO (2)
• Consultati medicul inainte de a va autoadministra o medicatie concomitenta (interactiuni medicamentoasesemnificative!)
• Atentie la dieta!!
- scad efectul ACO:brocoli, ceai verde,spanac,etc
• Atentie la tipul de preparat si la dozajul/comprimat!
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Reactii adverse
• Hemoragii
• Reactii alergice
• Necroza cutanata
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Interactiuni medicamentoase
CRESC efectul ACO AINS, algocalminAntibiotice/antifungiceAmiodaronaOmeprazolL-tiroxina
SCAD efectul ACO CarbamazepinaVegetaleFenobarbitalContraceptive orale
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Monitorizare ACO
• Recoltarea INR:
- la 3-7 zile in prima luna de tratament
- la maxim 4 saptamani ulterior
Repetare:
- Zilnica in caz de supradozaj
(pana la obtinere de INR terapeutic)
- La 3 zile in caz de sub-dozaj
- Posibilitatea monitorizarii la domiciliu (Coaguchek)
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Tinta tratamentului cu ACO
Depinde de patologia care a impus anticoagularea!!
• Uzual: INR=2-3
• Fontan: INR=1,8-2,2
• Proteze metalice mitrale: INR=2,5 – 3,5
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Contraindicatii ACO
• Sarcina in primul trimestru (potential teratogen!!)
• Lipsa de cooperare a copilului/parintilor responsabilide tratament
• Alergie la medicament
• Sangerari active
• Imediat inaintea interventiilor chirurgicale cu riscimportant de sangerare
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Restrictii pe durata ACO
• NU se vor face:
– Extractii dentare
– Injectii intramusculare
– Interventii chirurgicale (exceptand situatiile amenintatoarede viata, cand se contracareaza efectul ACO cu PPC)
– N.B. Angiografie, punctie lombara – risc de sangerare!!
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Situatii care impun oprirea ACO
• Oprire definitiva (eventual inlocuire cu antiagregant):
- INR necontrolabil
- necomplianta pacientului
Oprire temporara:
- hemoragii prin supradozaj izolat
- necesitatea de interventii chirurgicale/extractiidentare (se inlocuieste temporar cu HGMM)
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Tratamentul antiagregant
• Impiedica agregarea trombocitelor si hemostazaprimara (formarea trombusului alb)
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Tratamentul antiagregant
• Cel mai uzual antiagregant:
• ASPIRINA
Antiagregante mai putin folosite la copil:
Clopidogrel
Dipiridamol
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Indicatiile tratamentului antiagregant (1)
• AVC trombotic la copil
• Boala Kawasaki
• Sunturi sistemico - pulmonare
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Indicatiile tratamentului antiagregant (2)
• Dupa inchiderea interventionala a DSA/PCA cu device-uri (timp de 3-6 luni)
• Dupa montarea de stenturi la nivelul aortei istmice, ramurilor pulmonare,etc
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Indicatiile tratamentului antiagregant(3)
• Boala cardiaca ischemica (infarct de miocard)
• Fibrilatia atriala pe cord indemn
• Mentinerea patentei fistulelor arterio-venoase(dializa)
• In cazul indicatiilor de anticoagulare pe termen lung la care exista contraindicatii pt.ACO
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Aspirina (acid acetil - salicilic)
• In doza de 1-5 mg/kgc/zi are efect antiagregant
• Efectul antiagregant apare in 60 min de la administraresi dureaza pana la 10 zile
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Reactii adverse aspirina• Alergii
• Sangerari gastro-intestinale
• Astm bronsic
• Afectarea auzului
• Sindrom Reye
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Sindromul Reye• Disfunctie hepatica + encefalopatie
• Declansat de o infectie cu virus gripal sau de varicelala copil in tratament cu Aspirina
• Clinic: voma, iritabilitate, letargie, alterare progresivaa starii de constienta
• 25% progreseaza catre coma- deces sau deficit neurologic permanent
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Precautii ale tratamentului cu Aspirina
• Asocierea cu ACO – creste semnificativ riscul desangerare
- doar in cazuri atent selectionate
• In cazul interventiilor chirurgicale cu risc crescut desangerare, functie de balanta risc/beneficiu, poate finecesara stoparea tratamentului cu Aspirina cu minim7 zile anterior interventiei
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Aspirina - contraindicatii
• Alergie la aspirina
• Ulcer activ
• Antecedente de astm bronsic la administrarea de salicilati
• Hemoragie activa semnificativa
• Insuficienta renala sau hepatica severa
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Concluzii
• De retinut riscul potential letal al tratamentuluianticoagulant oral
• Importanta tratamentului antiagregant (nu trebuie“omis”, considerandu-se neimportant!)
• Asistenta medicala trebuie sa cunoasca riscul de sangerare in cazul acestor tratamente, avand in vedere manevrele cu potential hemoragic pe care le efectueaza
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Va multumesc!
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Acest material a fost documentat/ validat/ prezentat la sesiunile de formare în
cadrul proiectului „AD-COR Program inovativ de formare în domeniul cardiologiei
pediatrice” - POSDRU/179/3.2/S/152012, proiect cofinanțat din Fondul Social
Operațional Sectorial Dezvoltarea Resurselor Umane 2007-2013.
Beneficiar: Universitatea de Medicină și Farmacie „Carol Davila” București
Conținutul acestui material nu reprezintă în mod obligatoriu poziția oficială a Uniunii Europene sau a Guvernului României