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DABIGATRAN (PRADAXA)

Description

Dabigatran is a direct thrombin inhibitor (DTI) taken orally. It binds to thrombin thereby inhibiting the conversion of fibrinogen to fibrin. Dabigatran is effective after 2 h. It is contraindicated if the creatinine clearance (CrCl) < 30 mL/min.

Dose

Adult

  1. VTE prevention (CrCl > 50 mL/min) 110 mg 1–4 h postop, then 220 mg/day. If CrCl 30–50 mL/min give 75 mg 1–4 h postop, then 150 mg/day. For hip surgery, give for 28–35 days. For knee surgery, give for 10 days.

  2. Embolic stroke prevention—150 mg q 12 h. If elderly or creatinine clearance 30–50 mL/min, 110 mg q 12 h.

  3. DVT/PE treatment—150 mg q 12 h after 5 days of heparin therapy. Use 110 mg q 12 h if patient is elderly, has high bleeding risk or creatinine clearance 30–50 mL/min.

When to cease dabigatran for surgery/neuraxial anaesthesia

Renal function can be assessed by creatinine clearance. If the calculated creatinine clearance is > 50 mL/min, then:

  1. standard-risk procedures (e.g. cardiac catheterisation, colonoscopy without removal of large polyps, cholecystectomy)—cease dabigatran for 24 h

  2. high-risk procedures and neuraxial anaesthesia, insertion of pacemakers, major surgery—cease dabigatran for 48 h.

If the calculated creatinine clearance is 30–50 mL/min, then:

  1. standard-risk procedures—cease dabigatran for 48 h

  2. high-risk procedures/neuraxial anaesthesia—cease dabigatran for 4 days.

When to restart dabigatran after surgery

This depends on the assessed post-surgical bleeding risk. Restarting in 1 day for low-risk surgery and in 2–3 days for high-risk surgery is usually considered reasonable. If an epidural catheter is removed, wait at least 2 h before initiating dabigatran.

Emergency reversal of dabigatran

The thrombin time is very sensitive to the presence of dabigatran. PT and INR are unaffected.

  1. Idarucizumab (Praxbind) is a specific antidote for dabigatran. Give 5 g IV. Dabigatran can be resumed 24 h after idarucizumab. See Idarucizumab (Praxbind). If Praxbind is unavailable, consider FEIBA 50 U/kg and/or cryoprecipitate. See FEIBA-NF (factor VIII inhibitor bypass activity).

  2. Tranexamic acid 1 g IV q 8 h.

  3. Treatment as for any other major haemorrhage. See Blood loss—assessment, management and anaesthetic approach.

DALTEPARIN (FRAGMIN)

DANAPAROID (ORGARAN)

Description

Danaparoid is a low-molecular-weight heparinoid used in patients who require DVT/PE prophylaxis or treatment, but cannot have heparin/LMWH due to HIT type II. However, there is a risk of cross-reactivity with HIT antibodies. The drug acts mainly by inhibition of thrombin generation by:

  1. indirect inactivation of FXa

  2. inhibition of thrombin activation of FIX.

It is used ...

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