Once the dabigatran is cleared by the kidney, idarucizumab will have nothing to bind to and will have no effect. One important caveat is that there must be dabigatran in the bloodstream for idarucizumab to have any effect. This reversal of anticoagulation lasts 24 hours, which is an advantage over PCC, which has more transient effects. Studies show that administration of idarucizumab to healthy young volunteers, older volunteers ages 65-80, and volunteers ages 45-80 with mild or moderate renal impairment resulted in complete reversal of dabigatran's anticoagulant effects within minutes without any procoagulant effects. However, the efficacy of these methods has been questioned, and safety concerns have been raised regarding thrombotic risk of PCC. How should we manage the patient on dabigatran with an intracranial hemorrhage? Or the trauma patient who requires emergent surgery for their liver laceration who happens to be on dabigatran? Alternative reversal methods have been proposed, such as use of three- or four-factor PCC, fresh frozen plasma, or even emergent hemodialysis to remove circulating anticoagulant. Although the NOACs are associated with fewer serious bleeding complications than warfarin, life-threatening bleeding can still occur. This made emergency physicians and others who anticipate worst-case scenarios somewhat nervous. However, a major concern is that unlike warfarin, which can be reversed with Prothrombin Complex Concentrates (PCC) or fresh frozen plasma and vitamin K, dabigatran and the other NOACs lacked a dedicated reversal agent. Their pharmacokinetics are simpler, they don't have the pesky food and drug interactions that plague warfarin, they don't require monitoring and frequent dose adjustments, and importantly, they carry a lower risk of major bleeding complications. Dabigatran and other NOACs have several advantages over warfarin.
Dabigatran is a direct thrombin inhibitor used for stroke prevention in patients with atrial fibrillation and for treatment and secondary prevention of venous thromboembolism.
The new oral anticoagulants (NOACs) are skyrocketing in popularity, displacing warfarin as first-line anticoagulants for many patients.
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