February 14th, 2011

AF Guidelines Updated to Incorporate Dabigatran

Less than two months after the publication of the 2010 updated atrial fibrillation (AF) guidelines, the AHA, the ACC, and the HRS have released a new focused update incorporating recommendations and a discussion concerning the direct thrombin inhibitor dabigatran, which gains a Class I recommendation:

Class I: Dabigatran is useful as an alternative to warfarin for the prevention of stroke and systemic thromboembolism in patients with paroxysmal to permanent AF and risk factors for stroke or systemic embolization who do not have a prosthetic heart valve or hemodynamically significant valve disease, severe renal failure (creatinine clearance 15 mL/min), or advanced liver disease (impaired baseline clotting function). (Level of Evidence: B)

The update does not recommend routinely switching patients to dabigatran who are already successfully taking warfarin:

Because of the twice-daily dosing and greater risk of nonhemorrhagic side effects with dabigatran, patients already taking warfarin with excellent INR control may have little to gain by switching to dabigatran.

Here is the discussion about choosing between dabigatran and warfarin:

Selection of patients with AF and at least 1 additional risk factor for stroke who could benefit from treatment with dabigatran as opposed to warfarin should consider individual clinical features, including the ability to comply with twice-daily dosing, availability of an anticoagulation management program to sustain routine monitoring of INR, patient preferences, cost, and other factors.

One Response to “AF Guidelines Updated to Incorporate Dabigatran”

  1. This is huge. I am being asked by multiple patients whether they can be switched to dabigatran. The twice daily dosing is a far lesser burden than the frequent blood draws and dose adjustments. They are only dissuaded by the fact that it is not (yet) covered (at least in the VA) and that there is no antidote as with warfarin.

    It is exciting that the days of INR checking/waiting to be therapeutic/hunting down patients to adjust their warfarin doses may soon be over…but should we be a bit cautious? What about the increased risk of MI in the RELY trial – possibly due to platelet activation. Curious to hear others’ thoughts.