Clinical question: Can idarucizumab reverse anticoagulation effects of dabigatran in a timely manner for urgent surgery or in the event of bleeding?
Background: Reversing the anticoagulant properties of anticoagulants can be important in the event of a life-threatening bleed, or if patients taking these medications need urgent surgery or other interventions. Idarucizumab, a humanized monoclonal antibody fragment, can reverse anticoagulant activity of dabigatran, increasing its acceptance for prescribing physicians as well as patients.
Study design: Multicenter prospective single cohort study.
Setting: 173 sites, 39 countries.
Synopsis: Among 503 patients (median age, 78 years, indication for dabigatran included stroke prophylaxis in setting of atrial fibrillation for most) who had either uncontrolled bleeding (n = 301) or needing emergent surgery (n = 202), a single 5-g dose of idarucizumab was able to reverse anticoagulation rapidly and completely in more than 98% of these patients independent of age, sex, renal function, and dabigatran concentration at baseline. Specifically in 68% of the patients in the bleeding group (excluding intracranial hemorrhage) median time to the cessation of bleeding was 2.5 hours and median time to the initiation of the procedure in the emergent surgery group was 1.6 hours. Study limited by lack of control group.
Bottom line: Idarucizumab can be effective for dabigatran reversal among patients who have uncontrolled bleeding or need to undergo urgent surgery.
Citation: Pollack CV Jr. et al. Idarucizumab for dabigatran reversal: Full cohort analysis. N Engl J Med. 2017 Aug 3;377(5):431-41.
Dr. Kamath is a hospitalist and medical director of quality and patient safety, Duke Regional Hospital, Duke University Health System.