Values and preferences. This recommendation places relatively greater value on the ability of idarucizumab to reverse coagulation parameters indicative of dabigatran’s effect, its potential to decrease bleeding-related outcomes, and risks of urgent surgery and its safety and tolerability profile, and less value on the absence of a control group in the REVERSE-AD trial and on the cost of the drug.
Practical tip. In the acute, life-threatening bleeding situation in which standard resuscitation (such as local measures, transfusion, etc) is not anticipated to be sufficient (eg, intracranial hemorrhage), or in the situation in which it has not stabilized the patient, idarucizumab should be administered as soon as possible. Although dilute thrombin time and ecarin clotting time were used to identify the presence of dabigatran in REVERSE-AD, these tests are not widely available. Thrombin time and activated partial thromboplastin time are widely available and can qualitatively identify the presence of active dabigatran in a patient,65 however, obtaining these tests should not delay the administration of idarucizumab. In many instances of life-threatening bleeding, clinicians have to make a treatment decision on the basis of a history of dabigatran use rather than laboratory evidence. Renal function and timing of the last dose of dabigatran provide key information regarding the likely extent of remaining dabigatran effect. The timing of surgery might permit clinicians to obtain coagulation parameters like stat thrombin time or activated partial thromboplastin time to identify patients who no longer have dabigatran present, and who would be unlikely to benefit from idarucizumab. No dose adjustment for idarucizumab is required in patients with renal impairment. In some patients, coagulation parameters might increase between 12 and 24 hours after initial administration of idarucizumab, possibly reflecting redistribution of extravascular dabigatran into the intravascular space.64 Reversing dabigatran therapy exposes patients to the thrombotic risk of their underlying disease.
OAC should be reintroduced as soon as medically appropriate.