Repeated Administration of Idarucizumab to a Patient with Dabigatran Overdose

Summary

Idarucizumab is designed to reverse the anticoagulant effect of dabigatran. This case report describes the administration of three independent doses of idarucizumab to a 76-year-old man suffering from atrial flutter being treated with dabigatran to prevent ischaemic stroke. The last dose of dabigatran was administered in the morning of the same day the patient was transferred to hospital because of the need for urgent pericardium puncture. Baseline dTT (dilute thrombin time) reached 700 ng/mL as glomerular filtration (GF) dropped to 0.19 mL/s. The first dose of idarucizumab was administered prior to puncture and the clinical state was stabilized for the next 24 hours although dTT climbed to 400 ng/mL. The need for cannulation before dialysis required a second dose of antidote and a third dose was given prior to removal of the pericardium drain. Monitoring of dabigatran recovery showed that the reverse effect of idarucizumab lasted 12 hours, which is sufficiently long and reliable for urgent situations. Idarucizumab administration is not limited by age and/or renal impairment. We recommend repeated dTT examinations when the dabigatran baseline level exceeds 200 ng/mL and the antidote has been administered.

Zusammenfassung

Idarucizumab wurde entwickelt, um die antikoagulatorische Wirkung von Dabigatran aufzuheben. In dieser Kasuistik beschreiben wir die Gabe von drei Einzeldosen Idarucizumab bei einem 76-jährigen Mann, der unter Vorhofflattern litt und zur Schlaganfallprophylaxe mit Dabigatran behandelt wurde. Die letzte Dabigatrandosis war am Morgen des gleichen Tages verabreicht worden, an dem der Patient stationär eingewiesen wurde, weil eine dringende Perikardpunktion erforderlich war. Die dTT (Thrombinzeit in verdünnten Plasmaproben) erreichte bei Baseline 700 ng/ ml, während die glomeruläre Filtration (GF) auf 0,19 ml/s fiel. Die erste Dosis Idarucizumab wurde vor der Punktion verabreicht und der klinische Zustand stabilisierte sich in den nächsten 24 h, obgleich die dTT auf 400 ng/ ml anstieg. Da vor der Dialyse kanüliert werden musste, war eine weitere Dosis des Antidots erforderlich, eine dritte Dosis wurde vor der Entfernung der Perikarddrainage appliziert. Die Kontrollen bezüglich der Wiederherstellung der Dabigatranwirkung zeigten, dass die aufhebende Wirkung von Idarucizumab 12 h anhielt, was in Notfallsituationen hinreichend lange und zuverlässig ist. Die Gabe von Idarucizumab unterliegt keinen Beschränkungen durch Alter und/oder Niereninsuffizienz. Wir raten zu wiederholten dTT-Bestimmungen, wenn die Dabigatranspiegel bei Baseline mehr als 200 ng/ml betragen und das Antidot verabreicht wurde.

Keywords

Dabigatran - renal failure - pericardium tamponade - dTT - idarucizumab

Schlüsselwörter

Dabigatran - Nierenversagen - Herztamponade - dTT - Idarucizumab

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