Using Dabigatran in Patients With Stroke

Abstract

Atrial fibrillation (AF) is 1 of the most common causes of cardioembolic strokes accounting for at least 100 000 strokes each year in the United States. Strokes due to AF tend to be larger and more severe than other types of ischemic strokes with a 30-day mortality rate up to 24%.1 Anticoagulation with warfarin can reduce the risk of stroke in patients with moderate- and high-risk AF by ≥65%,2 yet the use of warfarin is limited by a number of factors, including concerns about bleeding, the need for frequent international normalized ratio (INR) monitoring as well as significant and common food and drug interactions.3–6 In October 2010, the Food and Drug Administration (FDA) approved the direct thrombin inhibitor dabigatran for primary and secondary stroke prevention (and systemic emboli prevention) in patients with AF.7 It is used as a fixed dose medication in most circumstances (150 mg twice a day if creatinine clearance is >30 mL/min or 75 mg twice a day if creatinine clearance is 15–30 mL/min) and does not require routine blood testing nor does it have any important interactions with most foods and medications. Dabigatran is not a substrate, inducer, or inhibitor of the cytochrome P450 enzymes.8 It has the potential to greatly expand clinicians' and patients' willingness to use anticoagulation in patients with high-risk AF. Often there is a gap between a new medication being approved and its widespread use. This is still true when one considers the underuse of warfarin in patients with AF, although there are a number of reasons for this finding. Patients with AF are often cared for by various physicians and other healthcare professionals in a variety of specialty and primary care areas and settings. For example, 25% of patients with AF first present with …