Abstract
Introduction. Dabigatran is an oral direct thrombin inhibitor which has been approved for prophylaxis of stroke in patients with atrial fibrillation. The use of dabigatran etexilate increased rapidly due to many benefits. However, questions have been raised constantly regarding the safety of dabigatran etexilate. Case. A 58-year-old Caucasian male with a history of recurrent paroxysmal atrial fibrillation status after pacemaker and end-stage renal disease on hemodialysis came to the Emergency Department with the complaint of severe epistaxis. He had been started on dabigatran 150 mg twice a day about 4 months ago as an outpatient by his cardiologist. His prothrombin time (PT) was 63 seconds with international normalized ratio (INR) of 8.8 and his activated partial thromboplastin time (aPTT) was 105.7 seconds. Otherwise, all labs were unremarkable including the liver function test. Dabigatran was stopped immediately. His INR and aPTT trended downward, reaching normal levels 5 days after admission. Conclusion. Dabigatran is contraindicated in patients with severe kidney insufficiency as it is predominantly excreted via the kidney (~80%). Elderly patients over 75 and patients with chronic renal impairment should be carefully evaluated before starting dabigatran. Despite studies showing only mild increase in aPTT and PT/INR in patients receiving dabigatran, close monitoring may be reasonable in patients with renal insufficiency.
Highlights
Dabigatran is an oral direct thrombin inhibitor which has been approved for prophylaxis of stroke in patients with atrial fibrillation
Dabigatran etexilate is a novel oral anticoagulant approved by the Food and Drug Administration (FDA) for stroke prophylaxis in patients with nonvalvular atrial fibrillation (AF)
The current guideline indicates that routine prothrombin time (PT)/international normalized ratio (INR) followup is not necessary for patients taking dabigatran
Summary
Dabigatran etexilate is a novel oral anticoagulant approved by the Food and Drug Administration (FDA) for stroke prophylaxis in patients with nonvalvular atrial fibrillation (AF). The use of dabigatran etexilate has increased substantially. 17 percent of patients with nonvalvular AF were started on dabigatran etexilate within just one year of approval [1]. A recent study showed that approximately 725,000 patients in the United States have been on dabigatran etexilate [1]. Questions have been raised consistently regarding the safety of dabigatran etexilate. We present a case of dabigatran etexilate-induced coagulopathy with extremely increased PT/INR in a patient with end-stage renal disease (ESRD)
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