Guidelines for reversing overdose of dabigatran (Pradaxa) and other new anticoagulants
August 29, 2012, 12:33 am
Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. Kaatz S et al. Am J Hematol 2012;87:S141-S145.
This article is the result of a huge effort:
Representatives from ten organizations that focus on thrombosis and anticoagulation convened a meeting in December 2011 and collaborated to develop pragmatic guidance to help clinicians manage the reversal of these new anticoagulants [dabigatran, apixaban, rivaroxaban] until more definitive and evidence-based guidelines are available. This meeting had members of the following organizations that belong to the Thrombosis and Hemostasis Summit of North American: Hemostasis and Thrombosis Research Society; Anticoagulation Forum; American Thrombosis and Hemostasis Network; North American specialized Coagulation Laboratory Association; American Heart Association; Association of Hemophilia Clinic Directors of Canada; Foundation for Women & Girls with Blood Disorders; National Blood Clot Alliance; Thrombosis Interest Group of Canada; and National Hemophilia Foundation
After representatives from all these groups met, they managed to come up with . . . nothing new. They reviewed many studies about how to change values of coagulation tests in rodents, which they admit have little to do with the clinical care of humans. Lacking real evidence, the group of “experts” came up with the following unsurprising recommendations on reversing the anticoagulation effects of these new thrombin inhibitors:
- supportive care (fluids, RBCs, control of bleeding source)
- discontinuation of anticoagulant
- activated charcoal if ingestion is “recent” (several hours)
The authors don’t discuss in detail the logistic problems of dialyzing a very sick patient with internal or external bleeding. They do mention that dialysis is not likely to be beneficial in cases of anticoagulation from apixaban or rivaroxaban, since both those drugs are more highly protein-bound than is dabigatran. The panel was split on whether or not to recommend 3-factor or 4-factor prothrombin complex concentrate (Beriplex, Octaplex), since these may increase risk of clotting and there have been no studies demonstrating benefit.
That said, some colleagues in our toxicology group believe that the article would be useful as a reference when consulting on a case and basically recommending just supportive care. I can see their point.