Fatal dabigatran-associated bleeding

We described a catastrophic outcome in a patient with acute kidney injury who was treated with dabigatran and was unable to tolerate placement of a hemodialysis catheter. Dr. Joson and colleagues bring up several points related to anticoagulation therapy for atrial fibrillation (AF) specifically assessing the risks and benefits, choice of agent, and appropriate dosage. While we agree that the use of dabigatran in this patient case was a poor choice, a comprehensive review of optimal selection and use of anticoagulants in AF was beyond the scope of our report. The patient’s renal function was estimated using ideal body weight. Use of an oral anticoagulant in patients with a CHADS2 score of 2 (as in our patient) or higher is a strong recommendation (grade 1A) from the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines.1 These guidelines further state that HAS-BLED has not been extensively validated and can only be used to modestly predict major bleeding events. The ACCP guidelines suggest that assessment of bleeding risk may show that risk is outweighed when the patient has a weak indication for anticoagulation (i.e., CHADS2 score of 0 or 1). In addition, we calculated the patient’s HAS-BLED score at the time of anticoagulation initiation at a slightly lower risk of 8.9%, given that the renal dysfunction was not present at this time. Dr. Joson and colleagues also suggest that the patient should not have received full-dose dabigatran. According to the U.S. prescribing information, a dosage of 150 mg twice daily is recommended unless the creatinine clearance is 15–30 mL/min, in which case 75 mg twice daily should be used.2 No dosage reduction is recommended for patients at higher risk for bleeding, and an intermediate dose of 110 mg that resulted in lower bleeding rates in the RE-LY study has not been approved for use in the United States.2,3