Dabigatran

Key points

• Oral direct thrombin inhibitor developed as an alternative to warfarin — advantage: no routine monitoring required.
• Indications: VTE prophylaxis after hip or knee replacement; stroke prevention in non-valvular AF with at least one risk factor.
• AF risk factors: previous stroke/TIA/systemic embolism, LVEF under 40%, symptomatic heart failure NYHA class 2 or more, age 75 or over, or age 65 or over with diabetes, coronary artery disease or hypertension.
• Haemorrhage is the major adverse effect; reduce dose in chronic kidney disease and do not prescribe if creatinine clearance is under 30 ml/min.
• RE-ALIGN (2013): higher bleeding and thrombotic events vs warfarin with mechanical valves, so contraindicated with prosthetic (mechanical) heart valves. A specific reversal agent, idarucizumab (Praxbind, 5 g IV), is available for life-threatening bleeding or emergency surgery.