Incidence and management of ischemic stroke and intracerebral hemorrhage in patients on dabigatran etexilate treatment

Dabigatran etexilate is an oral, reversible direct thrombin inhibitor and has been recently approved for the prevention of stroke in patients with non-valvular atrial fibrillation. This review describes the incidence and management of stroke and related complications in patients on dabigatran etexilate. Dabigatran is a rapidly acting, and highly selective and reversible inhibitor of thrombin. It also has a potent inhibitory effect on thrombin-induced platelet aggregation, making it effective in preventing both venous and arterial thrombosis. The activated partial thromboplastin time, ecarin clotting time and thrombin time are sensitive tests to evaluate the anticoagulant effects of dabigatran. The rate of ischemic stroke is significantly lower in patients on 150 mg of dabigatran etexilate as compared to 110-mg dose or warfarin (9.2, 13.4, 12 per 1,000 patients, respectively). As there is no standard coagulation test for dabigatran; treatment of acute stroke in such patients is debatable. Careful clinical consideration is required before administering thrombolytic therapy in this patient population. The rate of hemorrhagic stroke was 1.2 and 1.0 per 1,000 patients treated on 110 and 150 g of dabigatran, respectively. As there is no specific antidote, the only treatment option is discontinuation of the drug and supportive management. Other treatment options, hough not clinically proven, include specific reversal agents, which can be individualized according to the severity of the hemorrhage. Dabigatran should be discontinued before invasive procedures depending on the degree of renal impairment and risk of bleeding.