Dabigatran Plasma Measurement to Guide the Management of Acute Bleeding and Thrombotic Complications

Abstract

Oral anticoagulant therapy is recommended for the prevention and treatment of venous thromboembolism and to prevent stroke in non-valvular atrial fibrillation. Until a few years ago, vitamin K antagonists were the only drugs available, but direct oral anticoagulants have recently been introduced into clinical practice for the same clinical indications. Unlike the situation with VKAs, fixed-dose administration was proposed for DOACs, without the necessity for routine laboratory monitoring. However, in clinical practice a high inter-variability in DOAC plasma levels, independently of the type of drug and patient characteristics, was observed and the importance of measuring DOAC anticoagulant activity to support treatment decisions has therefore been recognized. We describe two clinical cases in order to highlight the role and importance of dabigatran-specific measurements to guide patient management in case of major complications.LEARNING POINTDirect oral anticoagulants (DOACs) have been used in clinical practice at fixed doses without laboratory monitoring.However, the importance of measuring DOAC anticoagulant activity to support treatment decisions, particularly in emergency conditions, has been recognized.The clinical value of DOAC measurement is highlighted in the two described cases where the anticoagulation level was taken into consideration when deciding on treatment.

A New Test for the Detection of Direct Oral Anticoagulants (Rivaroxaban and Apixaban) in the Emergency Room Setting

“…DOAC prescriptions have grown rapidly, and routine monitoring of coagulation in the context of DOAC therapy has not historically been recommended. Adverse events have mounted in recent years as these drugs are prescribed to increasingly complex patient populations, and a lack of U.S. Food and Drug Administration (FDA)-approved diagnostic tests to evaluate patient coagulation status in the context of DOAC therapy may: 1) increase the complexity of the continued adoption of these drugs for complex patient populations (such as those with renal disease, obesity, and polypharmacy) and 2) complicate clinical decision making in emergency and critical care settings (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15).…”