Repeated Administration of Idarucizumab to a Patient with Dabigatran Overdose

Idarucizumab is designed to reverse the anticoagulant effect of dabigatran. This case report describes the administration of three independent doses of idarucizumab to a 76-year-old man suffering from atrial flutter being treated with dabigatran to prevent ischaemic stroke. The last dose of dabigatran was administered in the morning of the same day the patient was transferred to hospital because of the need for urgent pericardium puncture. Baseline dTT (dilute thrombin time) reached 700 ng/mL as glomerular filtration (GF) dropped to 0.19 mL/s. The first dose of idarucizumab was administered prior to puncture and the clinical state was stabilized for the next 24 hours although dTT climbed to 400 ng/mL. The need for cannulation before dialysis required a second dose of antidote and a third dose was given prior to removal of the pericardium drain. Monitoring of dabigatran recovery showed that the reverse effect of idarucizumab lasted 12 hours, which is sufficiently long and reliable for urgent situations. Idarucizumab administration is not limited by age and/or renal impairment. We recommend repeated dTT examinations when the dabigatran baseline level exceeds 200 ng/mL and the antidote has been administered.