Guideline
There are several guidelines for the treatment of pulmonary embolism from different professional societies. These guidelines are merely a decision-making aid for the treating physicians, without being legally binding. They summarize the current study situation and incorporate it into the respective therapy scheme.
Depending on the clinical picture, they then provide guidelines for the further procedure. Advantages and disadvantages of different therapy options can also be taken from the guidelines, so that this can be taken into account in the individual decision for the respective case. As a rule, these guidelines are renewed and updated every few years so that the current state of research can be recorded in them.
For special patient groups, such as elderly people or pregnant women, the most important indications for their therapy are also recorded in the guidelines so that nothing is overlooked even in “exceptional cases”. The AWMF, the Association of the Scientific Medical Societies in Germany, is an association of numerous medical societies in Germany and one of the largest platforms for guidelines. For example, the current guideline on pulmonary embolism was published under the auspices of the German Society of Angiology at the end of 2015 and can be viewed free of charge on the Internet.
Anticoagulation- Blood clotting inhibitor
Anticoagulation is an anticoagulant therapy. After a pulmonary embolism has occurred, medication should be used to try to counteract a new thrombus in order to prevent pulmonary embolism or to dissolve the existing thrombus. Anticoagulation is a suitable therapeutic option for this, which can be carried out with the aid of various substances.
In most cases, anticoagulation is necessary for at least three months after such an event. The preferred substances here are Marcumar®, new oral direct anticoagulants such as Xarelto® or low-molecular-weight heparins such as Clexane®. They all inhibit the body’s own blood-clotting cascade in different ways and can therefore have different interaction and side effects.
Marcumar® is the trade name for phenprocoumon, a substance that inhibits the function of vitamin K in the body. Vitamin K is necessary for the production of different components of the coagulation cascade in the liver – if there is no functional vitamin K, the coagulation factors cannot be formed and blood coagulation is disturbed. Since the production of these coagulation factors usually takes several days, Marcumar® as a drug is relatively difficult to control and requires regular monitoring of blood coagulation activity.
For this usually the INR (English internationally Normalized ratio) is determined, a value which can give information about the extent of the coagulation inhibition. After a pulmonary embolism, a value between 2 and 3 is usually aimed at in the long term. In the case of long-term use of Marcuma, it should also be noted that there may be interactions between this drug and other drugs and even food.These can lead both to an increased effect with an increased risk of bleeding and to a reduced effect with an increased risk of thrombosis.
And last but not least, Marcumar® should be switched to heparin in good time before surgery due to its better controllability. Xarelto® is the trade name for a substance called rivaroxaban. This belongs to the group of new oral anticoagulants and inhibits the body’s own blood clotting.
In contrast to conventional Marcumar®, Xarelto® can be controlled relatively well and does not require an injection, as this drug can be taken in tablet form. Regular monitoring of the individual coagulation parameters is also generally not necessary with Xarelto®. However, this substance must not be given during active bleeding or during pregnancy and lactation.
Strong caution is also required in cases of severe renal failure and in combination with other anticoagulants, as this can result in an increased risk of bleeding. After a pulmonary embolism, Xarelto® is usually taken twice daily for the first three weeks after the event, and then only once daily until the drug is discontinued. Clexane® is the trade name for enoxaparin, a low molecular weight heparin.
Like all heparins in this group, Clexane® must be injected subcutaneously once or twice daily and is usually dosed according to body weight. Particular caution is required in cases of severe renal or liver failure, where dose adjustment is usually necessary. Otherwise, this substance is usually well tolerated and is also used during pregnancy and lactation.
