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Emergent reversal of Dabigatran
What is it:
Direct thrombin inhibitor used for stroke prevention in non-valvular atrial fibrillation
When do I worry about reversal:
Patients can have clinically important bleeding (GI hemorrhage, or Intracranial bleeding) or need reversal for emergent surgery
Patients with renal failure can have a prolonged medication effect
What can I do:
1. Activated charcoal: good for recent overdose or recent ingestion (within 2 hours)
2. Hemodialysis: around 60-65% can be removed within 2-4 hrs; putting in a dialysis line can be…bloody
3. FFP: in rat studies, has been shown to reduce the volume of intracranial hemorrhage. Unknown in humans. No good evidence of use based on coagulation mechanisms. Still worth a try though.
4. Recombinant activated factor VII: Has been shown to correct the bleeding time in animal studies. Probably the best bet in severe bleeding
5. Pro-thrombin complex concentrate: has been shown to decrease the bleeding time in animal studies
How do I monitor effect?
No great way here. Check aPTT and thrombin time (TT). At supra-therapeutic doses there is no good test.
Coming attractions: Dabigatran-fab for emergent reversal (see previous pearl: https://umem.org/educational_pearls/2415/)
References
Kaatz, S et al. Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. American Journal of Hematology. 2012.