--- title: "Dabigatran reversal (Praxbind)" canonical: "https://clinicaldecisions.refined.site/space/Haematology/31785123/Dabigatran+reversal+(Praxbind)" format: markdown --- > ℹ️ This guideline is to be used for severe to life threatening bleeding. For mild to moderate bleeding, see [Appendix](https://clinicaldecisions.atlassian.net/wiki/spaces/Haematology/pages/31785123/Dabigatran+reversal+Praxbind#Appendix). ### Severe bleeding and dabigatran reversal **Resuscitate/ABCs: **in patients on dabigatran with life threatening bleeding and shock, commence resuscitation measures as usual with oxygen and IV fluids and/or blood products. **Get help: **please notify the senior ED doctor on duty of any patients with life threatening or clinically significant bleeding. If you are worried, put out a 777 resus call. **Get dabigatran dosing history: **it is important to know when the patient took their last dose of dabigatran, especially if it was in the last 12 hours. **Baseline bloods: **please ensure that bloods taken include - venous blood gas, full blood count, creatinine, LFTs, coagulation screen including TCT, and group & hold. A venous blood gas is useful for getting a Hb reading quickly. **Calling the haematologist about dabigatran reversal: **the haematologist will want to know the severity of the bleeding, the timing of the last dabigatran dose, the patient’s creatinine, and that you have sent off a coagulation screen including TCT. This helps them make the decision about dabigatran reversal. If the bleeding is life threatening then you can call before the results are back, but make sure they have been sent. > ℹ️ **For ED patients only**: the ED SMO on duty can approve dabigatran reversal if specific criteria are met ([see below](https://clinicaldecisions.atlassian.net/wiki/spaces/Haematology/pages/31785123/Dabigatran+reversal+Praxbind#Criteria)) ### Dabigatran reversal Waitematā has access to the monoclonal antibody for dabigatran reversal called idarucizumab (Praxbind). To access this you will need to call the haematologist. You can read more about it in the [full guideline here](http://staffnet/QualityDocs/Quality%20Documentation/O2%20Medicine%20and%20Administration%20(Adults)/1e%20Haematology/%5bP%5d%20Dabigatran%20Reversal%20with%20Idarucizumab%20(Praxbind)%20Jan25.pdf). ### Definite indications for reversal include: - Life-threatening bleeding (critical organ bleeding) - Intracranial haemorrhage and prior to stroke thrombolysis - Aortic dissection - Confirmed or active haematemesis or melaena and either SBP ≤90 mmHg, oliguria, or >20 g/L fall in Hb - Retroperitoneal haematoma - In a situation when urgent procedure must be performed within 2-3 hours ### If reversal criteria met: - Call Blood Bank to order ONE idarucizumab (Praxbind) 2.5g vial, however two vials (5g) should be ordered **if intracranial haemorrhage or prior to stroke thrombolysis**. - Administer 2.5g as an IV infusion over 5 to 10 minutes or as a slow iv bolus (see section [5.2 Administration of full guideline](http://staffnet/QualityDocs/Quality%20Documentation/O2%20Medicine%20and%20Administration%20(Adults)/1e%20Haematology/[P]%20Dabigatran%20Reversal%20with%20Idarucizumab%20(Praxbind)%20Jan25.pdf)); **however 5g should be given upfront if patient meets criteria as above** - Take APTT/TCT immediately afterwards; a repeat dose of 2.5g is given if reversal is not obtained - Consider thrombotic potential/prophylaxis if appropriate - Supportive care with RBC/plasma transfusion as indicated by clinical situation ### > Macro (anchor) Criteria for ED patients needing reversal (must meet all): 1. Meet above clinical criteria 2. Dabigatran taken within previous 18 hours 3. Evidence of dabigatran effect – TCT > 80 and APTT normal or high > ℹ️ Contact the on-call Haematologist if criteria not met or unclear. ### Dose Give 2.5g (or 5g if patient meets criteria above) and repeat coagulation screen after administration. If TCT/APTT and/or dabigatran level still increased above the levels listed in the blue box on page 2 “Is there evidence of dabigatran effect?”, then give a second 2.5g dose (if only 2.5g given upfront). As reversal is immediate in almost all patients, do not delay urgent procedures whilst waiting for levels. Maximum of 5g in 24 hours unless discussed and approved by Haematologist. Discussion with the renal physicians regarding haemodialysis – especially in the setting of acute kidney injury- should be considered. **Reversal may be indicated in other conditions depending on the severity and should be discussed with the on-call haematologist:** - Clinically significant bleeding (but not life-threatening) such as blood loss ≥2 units in <7 days, or epistaxis ongoing but not catastrophic - Stroke in a patient on dabigatran where thrombolysis would usually be indicated - If your patient has less severe bleeding, there are guidelines available for management of bleeding in patients on novel anticoagulants (rivaroxaban or dabigatran) in the [Haematology CDS](https://clinicaldecisions.atlassian.net/wiki/spaces/Haematology/pages/31785294). > ℹ️ ### Appendix > ℹ️ > ℹ️ **Mild bleeding:** > ℹ️ > ℹ️ - Local haemostatic measures; mechanical compression > ℹ️ - Tranexamic acid. 15mg/kg, usually 1g in an adult, TDS to QID > ℹ️ > ℹ️ **Moderate bleeding:** > ℹ️ > ℹ️ Above plus: > ℹ️ > ℹ️ - Fluid replacement, as dabigatran is renally excreted > ℹ️ - Consider platelets if level <80 or if patient is taking an anti-platelet medication > ℹ️ - Activated charcoal 50g orally if dabigatran taken within the last 2 hours **and** no risk for aspiration. ###   *Dabigatran reversal ED guideline by W Lin (EM specialist), E Merriman (Haematologist), M Hanna (Haematologist)* --- Reviewed January 2025. 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