Successful hemostasis and reversal of highly elevated PT/INR after dabigatran etexilate use in a patient with acute kidney injury

Dabigatran etexilate is a novel oral anticoagulant indicated for anticoagulation in the management of atrial fibrillation and venous thromboembolism. Before its approval by the US Food and Drug Administration, warfarin, a vitamin K antagonist, was one of few oral anticoagulant options. The burden of therapeutic drug monitoring, dietary restrictions, and various drug interactions associated with warfarin have countered its extensive history of efficacy. Although dabigatran etexilate may alleviate some concerns encountered with warfarin therapy, there remains a paucity of evidence surrounding emergent reversal strategies in severe hemorrhage. We report here a 71-year-old man who presented to the emergency department with gastrointestinal hemorrhage precipitated by acute kidney injury while on dabigatran etexilate, with laboratory derangements highly uncharacteristic of dabigatran therapy (international normalized ratio, >10, and activated partial thromboplastin time, 93 seconds). After admission to the intensive care unit and 7 U of fresh frozen plasma, the patient remained hemodynamically unstable due to blood loss. Other observations were made that are poorly characterized in medical literature related to dabigatran: refractory hemorrhagic shock after 7 U of fresh frozen plasma, rapid correction of coagulation parameters (international normalized ratio, 1.7, and activated partial thromboplastin time, 44 seconds) achieved 4 hours after 26 U/kg of 4-factor prothrombin complex concentrate (Kcentra; CSL Behring, King of Prussia, PA), and with subsequent achievement of hemostasis. The patient was discharged to home 7 days later without sequelae.