Dabigatran in atrial fibrillation

This guideline lays out the criteria for the use of Dabigatran, a thrombin inhibitor.

It can be considered as an alternative to warfarin in non-valvular AF if at least one of the following applies:

  • Previous CVA / TIA / systemic embolism
  • LV ejection fraction < 40%
  • Heart Failure NYHA II or above
  • ≥ 75
  • ≥ 65 + DM or coronary artery disease or hypertension

It is much more expensive than warfarin, though at higher doses is more effective at reducing stroke. Its major benefits are in not having so many food and drug interactions and not needing monitoring. We will need to wait to see how this will be used locally.

Apart from cost, the main downside was that there was more major GI bleeding than with warfarin.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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  1. Louise Cockram
    Local Information on Use from Katie Hovenden Associate Director Medicines Management and CCG Development Portsmouth Clinical Commissioning Group (April 2012) "The decision about whether to start treatment with dabigatran etexilate should be made after an informed discussion between the clinician and the person about the risks and benefits of dabigatran etexilate compared with warfarin. For people who are taking warfarin, the potential risks and benefits of switching to dabigatran etexilate should be considered in light of their level of international normalised ratio (INR) control. It should be noted that there is no specific antidote to reverse the anticoagulant effect of dabigatran. Dabigatran should not be considered as a safer alternative to warfarin in elderly patients at risk of frequent falls or those with an increased bleeding tendency. Dabigatran is contraindicated in people with severe renal impairment, active clinically significant bleeding, organic lesions at risk of bleeding, impairment of haemostasis, and hepatic impairment or liver disease expected to have an impact on survival. The most common adverse events in people receiving dabigatran are anaemia, abdominal pain, diarrhoea, dyspepsia, gastrointestinal haemorrhage, genitourinary haemorrhage (patients may notice blood in their urine), nausea and nose bleeds. The SPC for Pradaxa should be referred to for full information on cautions, interactions and adverse effects. http://www.medicines.org.uk/EMC/medicine/24839/SPC/Pradaxa+150+mg+hard+capsules/ The implications of TA 249 and guidance on local imlementation will be discussed at the next Area Prescribing Committee meeting in April, meanwhile consensus from other sources suggests that: 1. Warfarin remains the anticoagulant of clinical choice for moderate or high risk atrial fibrillation patients with good INR control. 2. Dabigatran may be considered in patients with poor INR control despite evidence that they are complying, or allergy to or intolerable side effects from coumarin anticoagulants. "

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