Лікування раку може підвищувати ризик виникнення кровотечі

Кожна форма лікування раку: операція, променева або хіміотерапія може спричинити місцеву кровотечу з ран (при операції), пошкодження тканин (при променевій терапії) або системні антипроліферативні ефекти, що знижують кількість і функцію тромбоцитів (при хіміотерапії та деяких формах променевої терапії). Крім того, багато видів злоякісних пухлин пов'язані з ризиком кровотеч із слизової оболонки, наприклад, бронхіальна карцинома, урогенітальні кровотечі, рак голови та шиї. Основний ризик кровотечі, спричиненої застосуванням хіміотерапії, опосередкований мієлосупресивним ефектом терапії, що визначається кількістю тромбоцитів. Зазвичай, виражені мієлосупресивні ефекти виражаються у вигляді лейкопенії <1000 × 10⁹/л та кількості тромбоцитів <50 × 10⁹/л. Деякі види хіміотерапії можуть прямо впливати на тромбоцитарну функцію або систему коагуляції крові. Цього слід уникати. В подальшому, мієлосупресія зменшує кількість еритроцитів та знижує коефіцієнт безпеки у випадку виникнення кровотечі. Ступінь мієлосупресії суттєво змінюється залежно від терапії від легкої форми до затяжних періодів майже повної аплазії. Онкологи можуть найкращим чином визначити побічні реакції з боку системи згортання крові, пов’язані із спеціальною запланованою терапією. Незважаючи на це, взаємодія НПАК та специфічних хіміотерапевтичних засобів ще недостатньо вивчена і тому вимагає обережності.

Практичні рекомендації

Пацієнти із злоякісними пухлинами та ФП потребують багатопланового догляду з боку кардіологів та онкологів, у тому числі ретельне планування протитромботичної терапії.

У разі необхідності у антикоагулянтній терапії для пацієнтів зі злоякісними пухлинами, перевагу слід надати лікуванню антагоністами вітаміну К або гепарином у зв'язку з наявністю достатнього клінічного досвіду лікування цими препаратами, з можливістю здійснення пильного моніторингу та здатністю до усунення симптомів.

Наявність злоякісних пухлин у пацієнтів з ФП підвищує ризик інсульту. У зв'язку з цим за можливості, слід продовжити лікування антикоагулянтами, у тому числі НПАК.

На основі даних щодо пацієнтів з венозною емболією, терапія НПАК при дозовому режимі, необхідному для лікування ФП, також може попередити розвиток венозної емболії. Таким чином, при застосуванні НПАК немає потреби у додатковій антикоагулянтній терапії (наприклад, терапії НМГ).

У багатьох пацієнтів, що мають злоякісні пухлини та отримують терапію з помірним мієлосупресивним впливом, доцільним є продовження лікування НПАК.

До пацієнтів, що мають злоякісні пухлини та отримують НПАК і потребують хірургічного видалення пухлини, застосовуються ті ж принципи лікування, що й для пацієнтів, які потребують планового хірургічного втручання.

Пацієнтам, що отримують променеву терапію або хіміотерапію без вираженого мієлосупресивного впливу, слід продовжити лікування НПАК, за умови пристосування доз до очікуваних від лікування змін у функціях органів (особливо печінки та нирок).

При призначенні мієлосупресивної хіміотерапії та променевої терапії, багатопрофільна бригада лікарів, у тому числі кардіологи та онкологи повинні розглянути необхідність тимчасового зменшення дози або призупинки терапії НПАК. Слід розглянути доцільність особливих форм моніторингу, у тому числі:

(a) Проведення періодичних аналізів крові, включаючи підрахунок кількості тромбоцитів.

(б) Ретельне обстеження щодо симптомів кровотечі.

(в) Регулярний моніторинг функції печінки та нирок.

Для всіх пацієнтів, що отримують лікування антикоагулянтами, слід розглянути доцільність захисту шлунку за допомогою ІПП або блокаторів Н2-рецепторів.

Пацієнтів, що мають злоякісні новоутворення, слід повідомити про необхідність контролю симптомів кровотечі (петехійний крововилив, кровохаркання, чорний стул) та звернення до лікаря у разі виникнення цих симптомів.

 

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