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Pathophysiologie und Therapie der heparininduzierten Thrombozytopenie: Warum sind Antikoagulanzien mit Antithrombinaktivität sinnvoll bei HIT?

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Die Venenthrombose

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Zusammenfassung

Heparin bindet aufgrund seiner negativen Ladung an Thrombozytenproteine. Hierdurch werden Thrombozyten leicht aktiviert. Dies kann bei Krankheiten, bei denen per se die Thrombozyten aktiviert sind, z. B. periphere arterielle Verschlußkrankheiten, zum Abfall der Thrombozyten führen. Diese nicht-immunologischen Wechselwirkungen von Heparin und Thrombozyten sind klinisch von untergeordneter Bedeutung.

Viel wichtiger, da in einigen Fällen mit lebensbedrohlichen neuen thromboembolischen Komplikationen verbunden, ist die immunologische heparin-induzierte Thrombozytopenie. Betroffene Patienten bilden Antikörper, die an Komplexe aus Thrombozytenproteinen und Heparin binden. Diese Immun-komplexe aktivieren Thrombozyten und Endothelzellen. Dies führt zu einer massiven Verstärkung der Thrombinbildung mit der Konsequenz der Gerinnungsaktivierung. Daher müssen betroffene Patienten weiter antikoaguliert werden.

Hierfür stehen vor allem zwei Medikamente zur Verfügung: Rekombinantes Hirudin (Lepirudin, Refludan®) und Danaparoid-Natrium (Orgaran®). Hirudin ist ein direkter Thrombininhibitor, Danaparoid-Natrium zeigt vor allem anti-Faktor Xa-Aktivität.

Bei der Auswahl des geeignetsten Medikamentes für die weitere parenterale Antikoagulation sollten neben den pharmakologischen Besonderheiten der Medikamente, auch die Begleiterkrankungen des Patienten berücksichtigt werden.

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  1. A. Greinacher
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  1. Abteilung Innere Medizin, William-Harvey-Klinik, Am Kaiserberg 6, D-61231, Bad Nauheim, Deutschland

    Viola Hach-Wunderle

  2. Klinikum rechts der Isar I. Medizinische Klinik und Poliklinik, Ismaninger Straße 22, D-81675, München, Deutschland

    Wolfram Theiss

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Greinacher, A. (1999). Pathophysiologie und Therapie der heparininduzierten Thrombozytopenie: Warum sind Antikoagulanzien mit Antithrombinaktivität sinnvoll bei HIT?. In: Hach-Wunderle, V., Theiss, W. (eds) Die Venenthrombose. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-59959-0_10

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