Management of dabigatran after overdosage: two case reports and suggestions for monitoring

Strategies for the prevention and treatment of bleeding in patients treated with dabigatran: an update

INTRODUCTION

Although dabigatran is safer than vitamin K antagonists, bleeding still occurs. Bleeding is an important cause of short-term morbidity and rarely mortality and can also have long-term consequences that are often under-appreciated. After bleeding, patients often do not restart treatment or are poorly adherent, which is associated with increased thromboembolism and mortality. Consequently, we need strategies to prevent and treat bleeding in patients with atrial fibrillation treated with dabigatran.

AREAS COVERED

We review a) relevant dabigatran pharmacology, b) the burden and consequences of bleeding, c) how to identify patients at high risk of bleeding; and d) existing and novel approaches to prevent and treat bleeding in dabigatran-treated patients.

EXPERT OPINION

Concerns about the risk of bleeding associated with anticoagulant therapy and emerging evidence of increased risk of thromboembolism and mortality after bleeding highlight the need for improved approaches to prevention and treatment of bleeding. Future research priorities should focus on improving our ability to prevent bleeding by identifying modifiable risk factors and the development of safer agents. The current front runners include drugs that selectively target the contact pathway of coagulation (e.g. factor XI). Targeting upstream drivers of thrombosis (e.g. inflammation) could help to further reduce the risk of thromboembolism.

Dabigatran Level Before Reversal Can Predict Hemostatic Effectiveness of Idarucizumab in a Real-World Setting

Background: Idarucizumab has been included in guidelines for the management of bleeding or surgical procedure in dabigatran-treated patients without need for biological monitoring. The aim of the study was to assess the prognostic value of dabigatran plasma level before reversal to test the hemostatic efficacy of idarucizumab. The secondary objectives were (i) to analyze plasma dabigatran level according to the risk of rebound and (ii) to evaluate the incidence of post-reversal non-favorable clinical outcomes (including thromboembolism, bleeding, antithrombotic, and death) and antithrombotic resumption.

Methods and Results: This was an observational multicentric cohort study, which included all French patients who required idarucizumab for dabigatran reversal. Between May 2016 and April 2019, 87 patients from 21 French centers were enrolled. Patients received idarucizumab for overt bleeding (n = 61), urgent procedures (n = 24), or overdose without bleeding (n = 2). Among patients with major bleeding (n = 57), treatment with idarucizumab was considered effective in 44 (77.2%) of them. Patients who did not achieve effective hemostasis after reversal had a significantly higher mean level of plasma dabigatran at baseline (524.5 ± 386 vs. 252.8 ng/mL ± 235, p = 0.033). Furthermore, patients who did not achieve effective hemostasis after reversal had less favorable outcomes during follow-up (46.2 vs. 81.8%, p = 0.027). ROC curve identified a cutoff of 264 ng/mL for dabigatran level at admission to be predictive of ineffective hemostasis. No plasma dabigatran rebound was observed after reversal in patients with dabigatran plasma level < 264 ng/mL at baseline.

Conclusion: This retrospective study shows that dabigatran level before reversal could predict hemostatic effectiveness and dabigatran plasma rebound after idarucizumab injection.