Review: the bleeding patient on dabigatran
September 11, 2011, 12:02 am
Dabigatran: Review of Pharmacology and Management of Bleeding Complications of This Novel Anticoagulant. Ganetsky M et al. J Med Toxicol 2011 Sep 2 [Epub ahead of print]
Dabiagtran (Pradaxa) — a competitive direct thrombin inhibitor — is a new anticoagulant approved for the prevention of strokes in patients with non-valve-related atrial fibrillation. It has an important advantage over warfarin: predictable pharmacokinetics facilitates dosing and makes frequent monitoring of blood tests unnecessary.
However, there are also several potential disadvantages to dabigatran. For one thing, there is no lab test that accurately reflects the magnitude of anticoagulation effect. For another, since dabigatran inhibits the last step in the coagulation chain, there is no antidote that can stop or slow down bleeding caused by too much drug. While external or gastrointestinal hemorrhage in patients on dabigatran could be treated by controlling the source and replacing blood, bleeding into a closed space (cranium, spinal column, or pericardium) would present a more difficult problem.
This review article is a good summary of the problem and potential solutions, based on what is known at this time — which unfortunately is not much. The authors make the following pionts:
- Unlike heparin, dabigatran inhibits fibrin- and clot-bound thrombin.
- The risk of bleeding complications is increased in older patients and those with renal insufficiency.
- The elimination of dabigatran is enhanced by hemodialysis.
We will undoubtedly be hearing more about this subject in the near future. Until then, this paper is a comprehensive survey of current kno
To read my just-published Emergency Medicine News column “Dabigatran Toxicity: The Top 10 Questions”, click here.