When to stop Dabigatran (dabigatran) before a colonoscopy or polypectomy in a patient with impaired renal function and normal liver function tests?

From the Guidelines

For a patient with an eGFR of 23 mL/min/1.73m², the recommended time to stop dabigatran before a colonoscopy or polypectomy is 5 days, as the patient's renal function is significantly impaired. This is based on the most recent and highest quality study available, which suggests that for patients with a CrCl of 30-50 mL/min, dabigatran should be stopped 5 days before the procedure 1. Given the patient's eGFR is below 30 mL/min/1.73m², it is reasonable to extend this timeframe to ensure minimal residual anticoagulant effect at the time of the procedure. The risk of bleeding during colonoscopy or polypectomy is increased when anticoagulants remain active in the system, and impaired renal function significantly prolongs the half-life of dabigatran. Key considerations include:

• The patient's renal function and its impact on dabigatran clearance
• The type of procedure being performed and its associated bleeding risk
• The need for bridging anticoagulation in high-risk patients
• The timing of dabigatran resumption after the procedure, which should be individualized based on the specific bleeding risk and any interventions performed. It is essential to consult with the patient's cardiologist or a hematologist to determine the best approach for managing anticoagulation in this scenario.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Dabigatran Discontinuation Before Colonoscopy or Polypectomy

• The decision on when to stop dabigatran before a 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) should be based on the patient's renal function and the procedure's bleeding risk.
• Studies have shown that dabigatran is primarily cleared by the kidneys, and its plasma concentrations can be significantly affected by renal impairment 2, 3, 4, 5.
• For patients with severe renal impairment (eGFR < 30 ml/min/1.73m²), the risk of bleeding and dabigatran accumulation is higher, and closer monitoring is recommended 3, 4.
• The American College of Cardiology recommends stopping dabigatran at least 24 to 48 hours before procedures with a high risk of bleeding, but this may need to be adjusted based on the patient's renal function and other individual factors.
• In patients with an eGFR of 23 ml/min/1.73m², it is likely that dabigatran will need to be stopped for a longer period, potentially 3 days or more, to minimize the risk of bleeding during the procedure.
• However, the optimal timing for dabigatran discontinuation in this patient population is not well established, and the decision should be made on a case-by-case basis, taking into account the patient's overall clinical condition and the procedure's specific risks.

Considerations for Dabigatran Discontinuation

• The patient's renal function, as indicated by the eGFR, is a critical factor in determining the timing of dabigatran discontinuation.
• Normal LFT results suggest that liver function is not a significant concern in this case.
• The procedure's bleeding risk and the patient's individual risk factors, such as age and comorbidities, should also be considered when deciding on the optimal timing for dabigatran discontinuation.
• Close monitoring of the patient's renal function and bleeding risk is essential during the peri-procedural period to minimize the risk of complications.

Possible Answers

• A. 24 hours: may not be sufficient for patients with severe renal impairment
• B. 48 hours: may be adequate for some patients, but not for those with severe renal impairment
• C. 3 days: may be a more appropriate option for patients with an eGFR of 23 ml/min/1.73m²
• D. 1 week: may be excessive for most patients, but could be considered in exceptional cases with very high bleeding risk.