Bleeding and overanticoagulation with dabigatran

Levy, 2016Pollack, 2017Stangier, 2010

The following information applies to bleeding and overanticoagulation in patients taking dabigatran therapeutically; for information on the management of dabigatran poisoning, see Dabigatran poisoning in the Toxicology and Toxinology guidelines.

The risk of bleeding during dabigatran therapy is increased by advanced age (75 years or more), low body weight (less than 50 kg) and kidney impairment (calculated creatinine clearance [CrCl] less than 50 mL/min). For patient-associated factors that increase bleeding risk, see also Patient-associated factors that increase bleeding risk with anticoagulant therapy; clinical trials of dabigatran excluded patients with these risk factors.

If bleeding occurs in patients taking dabigatran therapeutically, it is necessary to stop dabigatran and provide supportive treatment. Identify and treat the source of bleeding to achieve haemostasis.

If a prolonged delay in excretion of dabigatran is anticipated (eg overdose, severe acute kidney injury) but urgent reversal is clinically unnecessary (ie no major bleed), consider using high-efficiency dialysis.

If it has been less than 2 hours since the last dabigatran dose, consider giving oral activated charcoal to remove unabsorbed dabigatran from the gastrointestinal tract. However, activated charcoal is an aspiration risk in nonintubated patients with an altered mental statusFrontera, 2016. See Gastrointestinal decontamination with activated charcoal for more information, including example dosages of activated charcoal.

Idarucizumab is a monoclonal antibody fragment that rapidly reverses the anticoagulant effect of dabigatran. The onset of effect is approximately 5 minutes. For patients taking dabigatran who develop life-threatening or uncontrolled major bleeding, or who require emergency surgery, use:

Once bleeding has been managed, whether and when to restart dabigatran therapy should be determined in consultation with a specialist.

The combination of dabigatran and dual antiplatelet therapy increases the risk of bleeding significantly. If bleeding occurs, consult the patient’s cardiologist before making any change to the antiplatelet therapy.