Dabigatran is a prodrug which is hydrolysed to its active from which directly inhibits thrombin (Factor II).
Dabigatran’s half-life is 12-17 hrs. However, Dabigatran undergoes 85% renal elimination, hence dosing and duration of action is much more dependent on renal function than the Factor Xa inhibitors1.
Indications include:
Dabigatran is not recommended where CrCl is <30ml/min and dose reduction is recommended where CrCl is 30-50ml/min.
Dabigatran should be omitted for at least 48 hrs prior to elective procedures, but this period should be increased in the presence of renal impairment4:
The Summary of Product Characteristics provides a full list of cautions, contraindications and interactions.
When restarting therapeutic dosing, maximal anticoagulation can be expected 2 hours post dose.
Where surgery is performed within 24 hours of Dabigatrin dosing or in the presence of renal failure, haematology advice should be obtained.
Association of Anaesthetists Guidelines recommend 48-96 hours cessation prior to central neuraxial block depending on renal function; this contrasts with 72-120 hours recommended by the American Society of Regional Anesthesia (ASRA). Dosing is not recommended with an epidural catheter in situ and 6 hours should elapse after catheter removal prior to dosing4.
Routine monitoring of Dabigatrin is not recommended; thrombin time is a marker of dabigatran activity, but is not commercially available. aPTT is also elevated but is not sufficiently sensitive to use as a clinical marker. PT may also be increased.
In most circumstances, specific reversal will not be needed, but within 24-48 hours of dosing/active bleeding this can be considered.
Praxibind (idarucizumab) is a monoclonal antibody licenced to specifically reverse Dabigatrin8.
Where idarucizumab is not available, alternative agents include Prothrombin Complex (Beriplex/Octaplex) and Tranexamic acid.
Preoperative assessment guidelines