From the Guidelines
For a patient with an eGFR of 23 mL/min/1.73m and normal liver function tests, dabigatran should be stopped at least 5 days before a colonoscopy or polypectomy. This recommendation is based on the guidelines from 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 extended discontinuation due to impaired renal function applies, and a more cautious approach is warranted. The American College of Chest Physicians clinical practice guideline also supports a pharmacokinetic-based approach for interrupting DOACs before elective surgery/procedure, considering the patient's renal function and the procedure's bleeding risk 1. Given dabigatran's primary elimination by the kidneys and the significant prolongation of its half-life in renal impairment, stopping the medication at least 5 days before the procedure is a prudent decision to minimize bleeding risks while considering the patient's thrombotic risk. Patients should consult their healthcare provider before stopping dabigatran, as some may need bridging anticoagulation depending on their individual risk factors. Dabigatran can typically be resumed 24-48 hours after the procedure if adequate hemostasis is achieved, with longer delays for high-risk procedures or complications. It's essential to consider the most recent and highest quality studies, such as those from 2021 and 2022 1, when making decisions about anticoagulation management in patients undergoing procedures.
From the FDA Drug Label
The FDA drug label does not answer the question.
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.