Intravenous Thrombolysis in Ischemic Stroke Patients on Dabigatran Treatment

IVT in Anticoagulated Patients: When Yes, When No

Patients with acute ischemic stroke (AIS) often take anticoagulants, primarily as a preventive measure for atrial fibrillation (AF). Generally, intravenous thrombolysis (IVT) is contraindicated in these patients, but it can be considered under certain conditions. For patients treated with warfarin, the INR value should be < 1.7. For patients on direct oral anticoagulants (DOACs), the drug must not have been administered in the last 48 hours, or specific laboratory tests should confirm the absence of its effect.

Reversal of Dabigatran Effect Using Idarucizumab

Since 2015, a specific antidote has been available for patients on dabigatran: a humanized monoclonal antibody, idarucizumab, which in a standard dose of 2× 2.5 g completely reverses the pharmacological effect of dabigatran within minutes. Therefore, IVT can be performed in dabigatran-treated patients when idarucizumab is administered.

Data from Real-World Clinical Practice

Data published in the Journal of Stroke and Cerebrovascular Diseases show experiences with IVT in these patients from real-world clinical practice in Czech stroke centers.

The study included 13 patients, 7 of whom were men. The average age of the patients was 70.0 ± 9.1 years, and the median NIHSS (National Institutes of Health Stroke Scale) score at admission was 7 points. Of these patients, 61.5% were taking dabigatran at a dose of 2× 150 mg daily. The antidote was administered 427 ± 235 minutes after the last dose of dabigatran, with an average measured activated prothrombin time of 38.1 ± 27.8 seconds and an average thrombin time of 72.2 ± 56.1 seconds. IVT was initiated on average 22 ± 18 minutes after antidote administration.

In 2 of these 13 patients, intracranial hemorrhage occurred after IVT, one of which was symptomatic. During a 3-month follow-up, a good clinical outcome (a value of 0–2 on the modified Rankin scale of self-sufficiency) was reported in 76.9% of patients. Recurrent AIS occurred in 2 patients, and 3 patients died.

Conclusion

The presented data support the assumption of the safety and efficacy of IVT in patients on dabigatran, provided its effect is antagonized by idarucizumab. To achieve the best effect, the authors recommend initiating IVT as soon as possible after administering idarucizumab.

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Source: Šaňák D., Jakubíček S., Černík D. et al. Intravenous thrombolysis in patients with acute ischemic stroke after a reversal of dabigatran anticoagulation with idarucizumab: a real-world clinical experience. J Stroke Cerebrovasc Dis 2018; 27(9): 2479–2483, doi: 10.1016/j.jstrokecerebrovasdis.2018.05.004.