Safety of Electroconvulsive Therapy in Patients Receiving Dabigatran Therapy

Abstract

Safety of electroconvulsive therapy (ECT) in patients chronically anticoagulated with warfarin has been established, despite warfarin having a narrow therapeutic range for toxicity and the need for intensive monitoring of the anticoagulant effect. A new anticoagulant medication, dabigatran, is a selective, reversible direct thrombin inhibitor recently approved in 2010 in the United States for thromboprophylaxis in patients with non-valvular atrial fibrillation. It has the potential advantage over warfarin with respect to similar therapeutic efficacy but without the need for frequent hematological monitoring and dose adjustments which are influenced by dietary changes and drug interactions. However, the safety in patients on dabigatran undergoing ECT has not been established. The aim of this case series is to describe the clinical course for two patients who received ECT while on dabigatran, and to assess for any adverse effects related to anticoagulation during the treatment course. We conducted a retrospective review of medical records for two patients who were identified through an electronic search to have received ECT in our psychiatric hospital and concurrently on dabigatran. We collected demographic and clinical information, indications for anticoagulation, pertinent laboratory values, and hemodynamic changes during ECT treatment. We also reviewed the hospital course to determine response and any adverse outcomes related to treatment. Two patients were identified, both males ages 78 and 80 years, and both received ECT for the treatment of major depressive disorder. Each had been prescribed dabigatran for the prevention of stroke and systemic thromboembolism secondary to atrial fibrillation, at the dosage of 150 mg twice daily, and had a creatinine clearance of greater than 30ml/min. They were treated with the recommended dose of 150 mg twice daily in patients with a creatinine clearance greater than 30ml/min. Both patients demonstrated excellent response to an acute course of ECT, receiving 11 and 5 treatments respectively, and achieved remission of depression, with only mild and transient confusion reported as side effects from ECT. They both had multiple medical comorbidities, but there were no reported adverse events related to the risk of increased bleeding due to anticoagulation including no reported cardiac, vascular, neurologic, or hematologic complications. In our review of two cases, no complications related to ECT and dabigatran were identified, and both had excellent response to ECT with remission of depression. To our knowledge, no studies have examined the safety of dabigatran treatment in patients undergoing ECT. Larger studies are needed to further establish its safety in ECT.