Dabigatran Excess: Case Report and Review of the Literature

Abstract

IntroductionNovel oral anticoagulants are increasingly used for stroke prophylaxis in patients with non-valvular atrial fibrillation. While these agents offer a more predictable pharmacokinetic profile, the lack of readily available laboratory tests to monitor the level of anticoagulation and absence of an antidote or established therapies to reverse the anticoagulant effect make management of cases of over-anticoagulation challenging.Case ReportIn this case report an 87-year-old man with a history of atrial fibrillation presented with dabigatran excess in the setting of life-threatening, acute renal and hepatic failure. The authors review the use of dabigatran in elderly patients, the available data on management of patients with excess anticoagulation, and the potential options for reversal of the anticoagulation effect.ConclusionFurther investigation into reliable means of monitoring and reversing the anticoagulant effect of dabigatran is crucial to the management of such patients.

Severe haematuria of lower urinary tract origin with low dose dabigatran use in three Indian elderly patients: unresolved issues in the safety of novel oral anticoagulants

“…9 There are many reports of dabigatran-induced bleeding in the elderly, the majority of them being in the presence of renal insufficiency and at the dose of 150 mg twice daily. 7 Here we have reported three cases of severe haematuria with dabigatran at the lowest possible therapeutic dose and in the presence of a normal renal function. The lower doses were employed intentionally considering the age of the patients.…”

Possible Interaction between Dabigatran and Ranolazine in Patients with Renal Failure

“…INR significantly increases only when the dabigatran plasma concentration is above the therapeutic range [6]. Some cases were reported when overdosing dabigatran caused INR to increase to 2.6 or even to 8.8 [8][9][10]. Usually, it occurred in patients with severe renal impairment [8][9][10].…”

Targeted Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy in Traumatic and Acquired Coagulopathy

“…Dabigatran, rivaroxaban, apixaban, and edoxaban cause lower rates of severe hemorrhage and intracranial bleeding events than warfarin [ 33 , 144 , 145 ]. Many reversal strategies have been suggested which involve the use of PCC, rFVIIA, and TXA in varying sequences and doses; however, this has not yet been standardized in the literature [ 31 , 143 , 146 - 159 ]. Bleeding events involving these agents will continue to be a clinical challenge until satisfactory monitoring tests and reversal strategies are found [ 158 ].…”

“…Bleeding events involving these agents will continue to be a clinical challenge until satisfactory monitoring tests and reversal strategies are found [ 158 ]. For dabigatran-associated bleeding, preliminary clinical data reveals that kaolin TEG and RapidTEG with or without ecarin can be used as a method of measuring the anticoagulant activity of dabigatran and quantifying reversibility [ 34 - 36 , 67 , 159 - 162 ].…”

“…However, small case reports and series have demonstrated successful use of PCC to completely reverse the anticoagulant effects of rivaroxaban. Currently there is little literature for using TEG-monitored PCC reversal of patients with acquired coagulopathy [ 31 , 143 , 146 - 159 ].…”