Reversal of Dabigatran
The incredible folks from hqmeded have put up a video on how to deal with bleeding patients on the new oral anticoagulant, dabigatran…
Here is the Hennepin County Reversal Protocol from the Video
What I took from this excellent resource:
- Thrombin Time is probably the best available way to monitor this drug, but due to lack of lab standardization, we cannot establish non-institutional ranges
- If aPTT is totally normal (<1.5x), unlikely that sig. drug effect is present
- Can be dialyzed and ~60% will be removed at 2-3 hour mark
- Despite the rec that FFP or PCC may be helpful, I am not sure why this would be the case. Factor VIIa or FEIBA seems the best choices, albeit not great or proven ones. I could totally be talking out of my arse, though.
- Activated charcoal will adsorb this drug if the patient took it <2 hours ago.
Here is a great review article on dabi.
The blog Clot Connect MD put up these references:
- van Ryn J. Dabigatran etexilate – a novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 2010; 103: 1116–1127.
- Crowther MA. Managing bleeding in anticoagulated patients with a focus on novel therapeutic agents. J Thromb Haemost 2009; 7 (Suppl 1):107–110.
- Eerenberg ES et al. Prothrombin Complex Concentrate reverses the anticoagulant effect of Rivaroxaban in healthy volunteers (abstract 1094; ASH annual meeting Dec 4-7, 2010, Orlando, FL).
- Morishima Y et al. Anti-Inhibitor Coagulant Complex, Prothrombin Complex Concentrate, and recombinant factor VIIa reverse prothrombin time prolonged by Edoxaban in human plasma (abstract 3319; ASH annual meeting Dec 4-7, 2010, Orlando, FL)
and linked to another reversal protocol from UNC
great post from EM Lit of Note, pointing to a study that PCCs will reverse Rivaroxaban, but Not Dabigatran (these were non-activated PCCs AFAIK)
“Reversal of Rivaroxaban and Dabigatran by Prothrombin Complex Concentrate.” www.ncbi.nlm.nih.gov/pubmed/21900088
Leon Gussow of the Poison Review has another excellent post on the top 10 questions on Dabigatran
Just published study indicates that Dabi may not cause enlarged hematomas in head bleeds (Circulation 2011;124:1654-1662)
For a better understanding (if you are smarter than me) of how Dabigatran Etexilate affects lab assays, see this article Thromb Haemostasis 2012;107(5) Douxfils et al.)
New article confirms a normal PTT and INR means no sig. dabigatran on board (PMID:23232017)
Letter to editor stating aPCC reverses dabi (British Journal of Haematology, 2013, 164, 296–310)
Exvivo study on human blood shows PCC and aPCC can reverse dabi (Critical Care 2014, 18:R27 )
Antidote seems to work: N Engl J Med 2015; 373:511-520 DOI: 10.1056/NEJMoa1502000
Dialysis works, but there may be rebound (10.1111/jth.13117)