From the Guidelines
For a patient with an eGFR of 23 mL/min/1.73m², normal liver function tests, taking dabigatran before a colonoscopy or polypectomy, the dabigatran should be stopped at least 5 days before the procedure. This recommendation is based on the guidelines provided by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) 1, which suggest that for patients on dabigatran with a CrCl (or eGFR) of 30–50 mL/min, the last dose should be taken 5 days prior to the procedure. Although the patient's eGFR is below 30 mL/min, the principle of stopping dabigatran 5 days before the procedure is supported by the need to ensure minimal residual anticoagulant effect, given dabigatran's prolonged half-life in renal impairment.
Key considerations include:
- The patient's renal function, as dabigatran is primarily eliminated by the kidneys, and impaired renal function prolongs its half-life, increasing bleeding risk.
- The bleeding risk of the procedure itself, with polypectomy carrying a higher risk than diagnostic colonoscopy.
- The potential need for checking a dilute thrombin time or ecarin clotting time before the procedure to confirm complete elimination, especially in high-risk patients.
- Resumption of dabigatran should typically occur 24-72 hours after the procedure, depending on the bleeding risk and the patient's thromboembolic risk.
The American College of Chest Physicians clinical practice guideline also supports a pharmacokinetic-based approach for the interruption of DOACs before an elective surgery/procedure, suggesting that for dabigatran-treated patients with impaired renal function (CrCl < 50 mL/min), interruption for 3 to 4 full days is required 1. However, given the patient's eGFR of 23 mL/min/1.73m², stopping dabigatran 5 days before the procedure aligns with the precautionary approach to minimize bleeding risk, as suggested by the guidelines and supported by the study findings 1.
From the Research
Stopping Dabigatran Before Colonoscopy or Polypectomy
To determine when to stop dabigatran before colonoscopy or polypectomy in a patient with an estimated glomerular filtration rate (eGFR) of 23 ml/min/1.73m² and normal liver function tests (LFT), we need to consider the pharmacokinetics of dabigatran in patients with renal impairment.
- Renal Impairment and Dabigatran: Studies have shown that dabigatran exposure is increased in patients with renal impairment, which correlates with the severity of renal dysfunction 2. The area under the plasma concentration-time curve (AUC) of dabigatran is significantly higher in patients with severe renal impairment compared to those with normal renal function.
- Dabigatran Elimination Half-Life: The terminal elimination half-life of dabigatran is approximately 28 hours in patients with severe renal impairment, which is twice that of patients with normal renal function 2.
- Guidelines for Stopping Dabigatran: Although there are no specific guidelines provided in the studies for stopping dabigatran before colonoscopy or polypectomy, the increased risk of bleeding in patients with renal impairment should be considered.
- Recommendations: Based on the pharmacokinetics of dabigatran, it is recommended to stop dabigatran at least 48 hours before colonoscopy or polypectomy in patients with severe renal impairment, such as an eGFR of 23 ml/min/1.73m² 2, 3. However, the optimal timing for stopping dabigatran may vary depending on individual patient factors, such as the presence of other bleeding risk factors.
Options for Stopping Dabigatran
Considering the above information, the options for stopping dabigatran before colonoscopy or polypectomy are:
- A. 24 hours: May not be sufficient for patients with severe renal impairment
- B. 48 hours: A reasonable option based on the pharmacokinetics of dabigatran
- C. 3 days: May be more appropriate for patients with severe renal impairment or other bleeding risk factors
- D. 1 week: May be excessive and increase the risk of thromboembolic events
Note: The optimal timing for stopping dabigatran should be individualized based on patient-specific factors, including renal function, bleeding risk, and thromboembolic risk.