Thrombotic events after discontinuing dabigatran: rebound or resumption?

Thorne, Katie; Dee, Stephen; Jayathissa, Sisira

doi:10.1136/bmj.e4469

Cited by 9 publications

(7 citation statements)

References 4 publications

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“…In summary, RCTs do not provide a clear conclusion regarding the risks associated with discontinuing DOACs in patient populations other than those postknee or hip replacement. It is important to remember that thromboembolic complications can be significant and include deep vein thrombosis, multiple splenic and renal infarcts, cerebral artery infarct, stent thrombosis, pulmonary embolism, or stroke (Thorne et al , ).…”

Section: Risk Associated With Discontinuation Of the Direct Oral Antimentioning

confidence: 99%

Novel anticoagulants: general overview and practical considerations for dental practitioners

et al. 2015

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Currently, 4 novel Direct Oral Anticoagulants (DOACs) were approved by the FDA. This review focuses on these agents and proposes a matrix for the general dentists to assess bleeding risk in dental management of patient on DOACs. The outline covers the pharmacology of DOACs (rivaroxaban, apixaban, edoxaban and dabigatran), bleeding complications, risk associated with discontinuation, monitoring/reversal, and implications for the dental practitioners. A total of 18 randomized controlled trials were identified with mixed results in regards to the risk for bleeding. Considering the pharmacology of DOACs and challenges in monitoring and reversing their effect, the dentist should consider carefully the management of patients on DOACs as it may differ from patients on conventional anticoagulants. Based on the type of dental procedure and the medical risk assessment, several general treatment approaches can be considered: continue DOACs, time dental treatment as late as possible after the last DOACs dose, discontinue DOACs for 24hrs, or discontinue DOACs for 48hrs. Based on the current reported dental literature, limited dental surgery may benefit from the first 2 conservative options. However, this needs to be proven in comparative clinical trials.

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Section: Risk Associated With Discontinuation Of the Direct Oral Antimentioning

confidence: 99%

Novel anticoagulants: general overview and practical considerations for dental practitioners

et al. 2015

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“…Data is emerging that discontinuation because of bleeding is much more dangerous [ 8 – 12 ] than discontinuation due to planned invasive procedures [ 13 – 16 ]. However, apart from case reports [ 17 , 18 ] and data from the Dresden registry [ 19 ] there has been no systematic analysis of the thromboembolic risk after NOAC discontinuation in real-life practice.…”

Section: Introductionmentioning

confidence: 99%

Risk of Thromboembolic Events in Patients with Non-Valvular Atrial Fibrillation After Dabigatran or Rivaroxaban Discontinuation – Data from the Ljubljana Registry

et al. 2016

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Background and AimInterruption of anticoagulant treatment with warfarin or non-vitamin K antagonist oral anticoagulants (NOAC) represents a vulnerable period with an increased risk of thromboembolic events. What is the incidence of thromboembolic events in real-life patients with non-valvular atrial fibrillation treated with NOAC who had a discontinuation or cessation of treatment in comparison to patients on continuous treatment?Patients and MethodsRegistry data from 866 patients with non-valvular atrial fibrillation, aged 74.3 (SD 9.8) years, with an average CHADS2 score of 2.1 (SD 1.2), who were started on dabigatran or rivaroxaban, were analysed for thromboembolic events and survival. Patients who had temporary or permanent discontinuation of NOAC were compared to patients on continuous NOAC treatment.ResultsAmong 866 patients started on NOAC, 705 were treated without interruption, 84 patients had temporary interruption (69 because of planned invasive procedures, 10 due to bleeding, 5 for other causes) and 77 had permanent cessation of NOAC treatment. In patients without interruptions, the incidence of thromboembolic events was 1.0 (95% CI 0.4–2.1) per 100 patient-years, while in patients with interruption/cessation the rate of thromboembolic events was 21.6 (95% CI 10.3–45.2) per 100 patient-years, p < 0.001. There was a distinct clustering of thromboembolic events in the first weeks of NOAC discontinuation with the median occurring on day 14 (range 1–37 days) after discontinuation.ConclusionDabigatran and rivaroxaban offered good protection against thromboembolic events during treatment, but interruption of NOAC treatment increased the short-term thromboembolic risk more than 20-fold.

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“…Although the rate of ischemic stroke is reported to be lower in patients under dabigatran as compared to phenprocoumon, the risk of bleeding is increased . The cause of stroke in the presented patient could be the absence of a prophylaxis against thromboembolic events from atrial fibrillation 5 days after discontinuation of dabigatran, low blood pressure, a rebound effect to discontinuation of dabigatran , or exsiccosis. She did not undergo acute thrombolysis because she was not seen by a neurologist in the acute phase of stroke, and cerebral MRI was carried out not earlier than on hospital day 9, and if she would have been seen, the contraindications dabigatran intake and intestinal bleeding would have allowed mechanical extraction of the clot exclusively.…”

Section: Discussionmentioning

confidence: 75%

Ischemic Stroke and Intestinal Bleeding Under Dabigatran in Metabolic Myopathy

Finsterer

Stöllberger

Paul³

et al. 2013

Cardiovascular Therapeutics

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SUMMARYObjectives: The subsequent occurrence of an ischemic thromboembolic event and a bleeding shortly after discontinuation of dabigatran has not been published. Case report: In an 89-year-old female with atrial fibrillation dabigatran had been started 11 days before admission, following a transitory ischemic attack. Phenprocoumon had been stopped 1 month earlier because of a hematoma after a fall. Although dabigatran was discontinued already on hospital day 1, she experienced an intestinal bleeding on hospital day three and an ischemic stroke on hospital day 6. As blood coagulation parameters were still abnormal on hospital day 2, intestinal bleeding was attributed to the prolonged antithrombotic effect or the interaction of dabigatran with the comedication. Stroke was attributed to the absence of a sufficient antithrombotic effect or a rebound effect 5 days after discontinuation of dabigatran. Clinical neurological examination additionally suggested a neuromuscular disorder. Conclusions: Ischemic stroke and intestinal bleeding may consecutively occur shortly after stopping dabigatran. Coagulation parameters may remain abnormal even 2 days after discontinuation of dabigatran. Dabigatran should be applied with caution in elderly patients with renal insufficiency who also take drugs, which enhance the absorption of dabigatran.

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Thrombotic events after discontinuing dabigatran: rebound or resumption?

Cited by 9 publications

References 4 publications

Novel anticoagulants: general overview and practical considerations for dental practitioners

Novel anticoagulants: general overview and practical considerations for dental practitioners

Risk of Thromboembolic Events in Patients with Non-Valvular Atrial Fibrillation After Dabigatran or Rivaroxaban Discontinuation – Data from the Ljubljana Registry

Ischemic Stroke and Intestinal Bleeding Under Dabigatran in Metabolic Myopathy

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