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Incomplete dabigatran reversal with idarucizumab
Aaron P Steele1, Jin A Lee1, William E Dager1
1a Department of Pharmacy Services , University of California, Davis Medical Center , Sacramento , CA , USA.
Clinical Toxicology (Philadelphia, Pa.)
|July 14, 2017
Summary
Urgent reversal of dabigatran with idarucizumab may be incomplete in cases of toxicity. Early detection of dabigatran toxicity is crucial, as the international normalized ratio (INR) can indicate high drug levels.
Area of Science:
- Pharmacology
- Hematology
- Toxicology
Background:
- Direct oral anticoagulants (DOACs) are increasingly used, raising concerns about urgent reversal.
- Idarucizumab is a specific reversal agent for dabigatran, designed to neutralize its anticoagulant effect.
Observation:
- Two cases presented with supratherapeutic dabigatran levels and incomplete reversal despite recommended idarucizumab doses.
- Patients experienced severe hemorrhaging and shock, refractory to standard treatments including idarucizumab, blood products, and FEIBA.
Findings:
- The standard 5g dose of idarucizumab was insufficient for complete dabigatran reversal in these cases.
- Elevated dabigatran concentrations were observed, suggesting potential for toxicity beyond the reversal agent's capacity.
Implications:
- These findings highlight the potential for idarucizumab failure in severe dabigatran toxicity.
- Early recognition of dabigatran toxicity, possibly using INR as a surrogate marker, is critical for patient management.
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