Yoğun Bakımda COVID-19 Hastalarında Antikoagülan ve Antiplatelet Tedavi Protokolleri
Özet
Covid-19 enfeksiyonu, akciğer epiteli ile damar endotelindeki ACE-2 reseptörlerine bağlanarak endotel hasarına, sitokin fırtınasına ve koagülopatiye yol açmaktadır. Bu süreçte gelişen mikrovasküler ve makrovasküler trombozlar organ yetmezliği ile ölüme neden olabilmektedir. Covid-19 koagülopatisi; özellikle belirgin D-dimer ve fibrinojen yüksekliği ile minimal protrombin zamanı (PZ) ve trombosit değişiklikleriyle karakterize bir "tromboinflamasyon" tablosudur. Ağır hastalarda venöz tromboemboli (VTE) ve pulmoner emboli (PE) riskinin artması nedeniyle, kontrendikasyon bulunmayan tüm yatılı hastalara düşük molekül ağırlıklı heparin (DMAH) ile profilaksi uygulanması önerilmektedir. DMAH, hemostatik ve antiinflamatuvar faydalarının yanı sıra viral spike proteinine bağlanarak antiviral etki de gösterir. İlaç etkileşimleri ve kanama riskleri nedeniyle warfarin ile direkt oral antikoagülanların (DOAK) rutin kullanımı tercih edilmemektedir. Antiplatelet tedavilerde ise aspirinin özellikle kardiyak komorbiditesi olan hastalarda mortaliteyi azalttığı gözlenmiştir. T.C. Sağlık Bakanlığı kılavuzuna göre, koagülopati belirteçleri (trombosit <100.000/µl, D-dimer artışı vb.) izlenerek risk altındaki hastalara enoksaparin veya standart heparin ile kişiselleştirilmiş profilaksi uygulanmalı ve duruma göre tedavi dozu belirlenmelidir.
Covid-19 infection binds to ACE-2 receptors in the lung epithelium and vascular endothelium, leading to endothelial damage, cytokine storm, and coagulopathy. Microvascular and macrovascular thromboses developing during this process can cause organ failure and death. Covid-19 coagulopathy is a "thromboinflammation" condition characterized particularly by prominent D-dimer and fibrinogen elevation with minimal changes in prothrombin time (PT) and platelets. Due to the increased risk of venous thromboembolism (VTE) and pulmonary embolism (PE) in severe patients, prophylaxis with low-molecular-weight heparin (LMWH) is recommended for all hospitalized patients without contraindications. LMWH exhibits antiviral effects by interacting with the viral spike protein, in addition to its hemostatic and anti-inflammatory benefits. The routine use of warfarin and direct oral anticoagulants (DOACs) is not preferred due to drug interactions and bleeding risks. Among antiplatelet therapies, aspirin has been observed to reduce mortality, especially in patients with cardiac comorbidities. According to the Republic of Turkey Ministry of Health guideline, coagulopathy markers (platelets <100,000/µl, D-dimer elevation, etc.) should be monitored, and personalized prophylaxis with enoxaparin or standard heparin should be administered to patients at risk, with the treatment dose determined based on the clinical status.
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TC. Sağlık Bakanlığı COVID-19 Rehberi- Antisitokin-Antiinflamatuar Tedaviler, Koagülopati Yönetimi 07.11.2020. https:// covid19.saglik.gov.tr/TR-66341/antisitokin-antiinflamatuar-tedaviler-koagulopati-yonetimi.html
