Successful use of laboratory monitoring to facilitate an invasive procedure for a patient treated with dabigatran

PURPOSE: A case in which novel and traditional laboratory markers were successfully used to determine surgical intervention timing in an elderly patient receiving dabigatran for atrial fibrillation is reported. SUMMARY: An 86-year-old woman who was taking dabigatran for atrial fibrillation suffered a right femoral neck fracture requiring surgical intervention. Dabigatran was withheld once the patient was admitted to the hospital, and the pharmacy inpatient anticoagulation management team was consulted for guidance on determining appropriate scheduling of surgical intervention with regard to the time since her most recent dabigatran dose to minimize bleeding complications. The team recommended delaying surgery, as dabigatran clearance would likely take 3-5 days and an ecarin chromogenic assay (ECA) dabigatran value of <50 ng/mL would be desirable before surgical intervention. During her hospitalization, novel and traditional laboratory markers for dabigatran, such as ECA value, activated partial thromboplastin time, thrombin time, and prothrombin time, were measured and followed closely to determine the best time to perform surgical intervention to minimize bleeding risk. Renal dysfunction likely delayed dabigatran elimination in the patient and may have led to potential accumulation of dabigatran. The patient ultimately had to wait 5 days after the last dabigatran dose for surgical intervention. CONCLUSION: Coagulation assay monitoring for dabigatran, with emphasis on an ECA dabigatran concentration of <50 ng/mL, was used to assess safety regarding bleeding risk before a nonemergent surgical procedure in an 86-year-old woman with a right femoral neck fracture.