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Aktuelle Rheumatologie 2016; 41(02): 137-144
DOI: 10.1055/s-0041-108739
Übersichtsarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Was sollte der Rheumatologe über Hämostaseologie wissen?

What Rheumatologists should Know About Haemostaseology
T. Dörner
1   Med. Klinik m.S. Rheumatologie und Klinische Immunologie, Charite Universitätsmedizin Berlin
› Institutsangaben
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Publikationsverlauf

Publikationsdatum:
07. März 2016 (online)

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Zusammenfassung

Entzündungs- wie Gerinnungsprozesse sind Teil komplexer Abwehrmechanismen zur Erhaltung der körperlichen Integrität und Homoiostase. Beide haben daher Gemeinsamkeiten, z. B. sind sie durch vielfältige Interaktionen auf zellulärer und humoraler Ebene vernetzt und nutzen schrittweise Amplifikationen. Von Bedeutung dabei ist, dass Entzündungs- und Gerinnungsaktivierung offenbar simultan im Rahmen von Abwehrprozessen erfolgen. Diese Verknüpfungen haben somit klinische Konsequenzen bzw. Korrelate, wie dies für Patienten mit akuten (Sepsis, Harnwegsinfekt, pulmonale Infekte, usw.) als auch chronischen (rheumatische Erkrankungen, entzündliche Darm- und Atemwegserkrankungen, usw.) Entzündungen durch erhöhte thromboembolische Morbiditäts- und Mortalitätsrisiken belegt werden kann. Die vorliegende Arbeit gibt einen Überblick zu klinischen und pathophysiologischen Aspekten der Wechselwirkung von Inflammation und Hyperkoagulabilität bei rheumatischen Systemerkrankungen (rheumatoide Arthritis, Kollagenosen, Vaskulitiden). Die insgesamt erhöhten Risiken für venöse thrombembolische Ereignisse und Lungenembolien (VTE) bei diesen Krankheiten bestehen v. a. in Phasen erhöhter Krankheitsaktivität, Immobilisation, die Notwendigkeit von operativen Eingriffen, Einsatz höherer Glukokortikoiddosen und sollte hinsichtlich einer strikten Thromboseprophylaxe berücksichtigt werden. Der rheumatologische Sonderfall Antiphospholipidsyndrom wird hinsichtlich seiner speziellen, klinischen Aspekte besprochen. Die Evidenz für einzelne VTE-Prophylaxemaßnahmen (physikalische, medikamentöse Maßnahmen) ist für rheumatische Erkrankungen unzureichend belegt und bedarf weiterer Untersuchungen. Schließlich werden aktuelle Aspekte der Antikoagulationsmöglichkeiten einschl. direkter oraler Antikoagulantien und möglicher Schnittstellen zu entzündlich-rheumatischen Erkrankungen diskutiert. Das deutlich erhöhte VTE-Risiko bei Patienten mit rheumatischen Erkrankungen erfordert dessen Berücksichtigung in der Prophylaxe, Diagnostik und Therapie.

Abstract

Inflammation as well as coagulation processes are part of complex defence mechanisms, which serve to maintain physical integrity and homeostasis. Therefore, they share a number of common features such as a network of manifold interactions on a cellular and humoral level or the use of stepwise amplification. Importantly, inflammation and coagulation are apparently activated simultaneously in the course of immune defence processes. These connections therefore have clinical implications or correlates, as has been proven for patients with acute (sepsis, urinary tract infections, pulmonary infections, etc.) and chronic (rheumatic diseases, inflammatory diseases of the intestinal and respiratory tract, etc.) inflammations, who are at an increased risk of morbidity and mortality due to thromboembolic events. This paper provides an overview of clinical and pathophysiological aspects of the interactions between inflammation and hypercoagulability in patients with systemic rheumatic diseases (rheumatoid arthritis, connective tissue diseases, vasculitis). The overall increased risks of venous thromboembolic events and pulmonary embolism (VTE) in these diseases most notably exist in phases of increased disease activity or immobilisation, or in phases in which surgical procedures are required or higher doses of glucocorticoids are used. These risks should be considered in decisions on strict thrombosis prophylaxis. The antiphospholipid syndrome, a special entity in rheumatology, will be discussed in the light of its specific clinical aspects. Evidence regarding individual measures to prevent VTE (physical measures, medication) is insufficient for rheumatic diseases and requires further investigation. Finally, current aspects of anticoagulation options will be discussed, including direct oral anticoagulants and possible interfaces with inflammatory rheumatic diseases. The clearly increased risk of VTE in patients with rheumatic diseases must be considered in the prevention, diagnosis and treatment of inflammatory rheumatic diseases.

Schlüsselwörter

Rheumatoide Arthritis - Thrombose - Koagulation - Lungenembolie

Key words

rheumatoid arthritis - thrombosis - coagulation - pulmonary embolism
 

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