Q: 54 year old male on Pradaxa (Dabigatran) for Atrial fibrillation is now admitted to ICU from OR as patient continue to bleed generally from Incision as well as orifices, after emergent abdominal hernia repair. Patient was re-explored in OR twice to rule out any surgical bleed. Patient received multiple blood products including FFP, PCC, Platelets and 10 units of pRBC. What else could be done to stop bleeding secondary to Pradaxa?
 

Answer: Trial of Dialysis

All new oral Direct Thombin Inhibitors  (DTIs) can cause problems in OR and ICU as they don't have any effective reversal. Pradaxa is mostly excreted via Kidney and some literature supports success in reversing bleeding with dialysis. In contrast, Xeralto (Rivaroxaban) is highly protein bound and major metabolic pathway is via liver, and cannot be reversed with dialysis.

References:

Stangier J, Rathgen K, Stahle H, Mazur D. Influence of renal impairment on the pharmacokinetics and pharmacodynamics of oral dabigatran etexilate: an open-label, parallel-group, single-centre study. Clin Pharmacokinet. 2010;49:259-268. 

Wanek MR, Horn ET, Elapavaluru S, Baroody SC, Sokos G. Safe use of hemodialysis for dabigatran removal before cardiac surgery. Ann Pharmacother. 2012;46:e21.