An Experience with Reversal of Dabigatran with Two Doses of Idarucizumab, Hemodialysis, and Time in the Setting of Anuric Renal Failure and Major Gastrointestinal Bleeding

Dabigatran is a direct oral anticoagulant (DOAC) FDA approved for nonvalvular atrial fibrillation and venous thromboembolism. Benefits of dabigatran when compared to warfarin sodium include a shorter half-life and lack of need for routine monitoring. Recently idarucizumab was FDA approved for dabigatran reversal in the setting of life-threatening bleeding. Idarucizumab binds dabigatran neutralizing its activity. There is limited data regarding efficacy of redosing of idarucizumab as well as clearance of dabigatran in the setting of anuric renal failure. We present a case of a patient on chronic dabigatran for atrial fibrillation who was admitted for septic shock and developed gastrointestinal bleeding, anuric renal failure requiring dialysis for several days; despite two doses of idarucizumab and hemodialysis, the thrombin time remained elevated. Subsequently dabigatran levels returned and confirmed delayed clearance despite these interventions.