What neurosurgeons need to know about dabigatran etexilate (pradax(®)/pradaxa(®)/prazaxa(®))

Dabigatran etexaliate is a novel oral anticoagulant that directly inhibits thrombin. It offers a number of substantial medical benefits over other oral and parenteral anticoagulants but its advent raises important neurosurgical considerations. Dabigatran has important potential benefits. Unlike warfarin, it does not require routine blood tests to monitor its anticoagulative effect and there is no need for dose titration. Drug interactions are greatly simplified when compared to warfarin as dabigatran is not metabolized by cytochrome p450 isoenzymes. As a result, dabigatran has been approved in many jurisdictions for DVT prophylaxis after orthopaedic surgery and also for the prevention of embolic events associated with non-valvular atrial fibrillation. There are, however, important neurosurgical challenges associated with regular dabigatran use. Unlike current anti-coagulants, there is no specific reversal agent for dabigatran. Known reversal options include activated charcoal (within one to two hours of intake) and renal dialysis. Protamine sulfate and vitamin K are unlikely to affect the activity of dabigatran. Platelet concentrates will not inactivate dabigatran's anti-thrombin properties. Assessing the degree of anticoagulation is difficult as conventional markers of serum coagulability are typically normal in patients taking dabigatran. The potential neurosurgical challenges of dabigatran were cast in sharp relief by a recent case report from the United States that is considered in this note. In the absence of a clear reversal pathway, we propose a treatment algorithm for chronic dabigatran use based on the replacement of any deficient factors and rapid access to renal dialysis.