When to stop Dabigatran (dabigatran) before 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/1.73m and normal liver function tests, dabigatran should be stopped at least 5 days before a colonoscopy or polypectomy. The management of dabigatran in patients undergoing elective procedures like colonoscopy or polypectomy, especially those with impaired renal function, is critical to balance the risk of bleeding against the risk of thromboembolism. Given the patient's eGFR of 23 mL/min/1.73m, which indicates severe renal impairment, the clearance of dabigatran will be significantly prolonged because dabigatran is primarily eliminated by the kidneys 1.

Key Considerations:

• The patient's renal function is a crucial determinant of dabigatran's half-life, with impaired renal function leading to a longer half-life and thus a longer time to clear the drug from the system.
• For patients with a CrCl of less than 30 mL/min, dabigatran's use is generally contraindicated due to the increased risk of bleeding, but in cases where it is used, a longer interruption period is recommended before procedures with a high risk of bleeding.
• The most recent and highest quality guidelines recommend that for patients on dabigatran with a CrCl of 30–50 mL/min, the last dose should be taken 5 days prior to the procedure, but given this patient's eGFR is below 30 mL/min, an even more cautious approach may be warranted 1.
• The American College of Chest Physicians guideline suggests that for dabigatran-treated patients with severely impaired renal function (CrCl < 30 mL/min), interruption for at least 4 to 5 days may be required before a high-bleeding-risk surgery or procedure 1.

Recommendations:

• Stop dabigatran at least 5 days before the procedure to minimize the risk of bleeding, considering the patient's severe renal impairment and the procedure's bleeding risk.
• Consultation with both the gastroenterologist and the physician who prescribed dabigatran is essential to create an individualized plan, especially considering the patient's high thromboembolic risk that might require bridging therapy.
• Dabigatran can typically be resumed 24-48 hours after the procedure if adequate hemostasis is achieved, with longer delays considered for high-bleeding-risk procedures 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.