Use of Idarucizumab for dabigatran reversal: Emergency department experience in two cases with subdural haematoma

Abstract

IntroductionIdarucizumab is the first effective humanized monoclonal antibody fragment developed specifically as a reversal agent for dabigatran, a Direct Oral Anticoagulant. Despite recent trials demonstrating reversal of clinically relevant bleeding, there is a paucity of data on use outside the trial setting. This manuscript describes the use of Idarucizumab to reverse dabigatran in two patients presenting to the emergency department of a major tertiary hospital with acute traumatic subdural haematomas (SDH). MethodsPatients were identified through retrospective review of medication dispensing systems and electronic medical records. ResultsTwo cases of Idarucizumab use were identified. Case 1 was of a 63-year-old male who presented following a motorcycle crash. Case 2 was of a 77-year-old male who presented with a 3-week history of ataxia and recurrent falls. Both patients were taking dabigatran for atrial fibrillation (AF). CT Brain revealed acute SDH with clinical indications for urgent surgical evacuation. Serum dabigatran levels were obtained on arrival in the emergency department with levels of 155ng/ml and 110ng/ml (reference range 117–275ng/ml). Idarucizumab for dabigatran reversal was commenced; Case 1 received 5g Idarucizumab as an intravenous bolus dose, while Case 2 received 5g Idarucizumab as two 2.5g intravenous infusions. Serum dabigatran levels for Cases 1 and 2 were 0ng/ml at 75min and 340min post Idarucizumab administration respectively. Both patients proceeded to craniotomy with evacuation of the SDH. There was no extension of the SDH in either case. Anticoagulation was withheld until outpatient clinic review, and both patients transferred for rehabilitation prior to discharge home. ConclusionIdarucizumab was clinically effective for reversing dabigatran, resulting in undetectable serum levels, and should be considered in patients presenting to hospital with clinically significant bleeding associated with dabigatran therapy.