How long should Pradaxa (dabigatran) be held before an Esophagogastroduodenoscopy (EGD)?

Timing of Pradaxa (Dabigatran) Discontinuation Before EGD

For patients on dabigatran (Pradaxa) undergoing an EGD, the last dose should be taken at least 48 hours before the procedure if renal function is normal, or 72 hours before if creatinine clearance is 30-50 mL/min. 1

Risk Stratification and Management Algorithm

Step 1: Determine EGD Procedure Risk

First, determine if the EGD is diagnostic only or therapeutic:

• Low-risk EGD: Diagnostic procedures with or without biopsy, biliary/pancreatic stenting 1

  • Omit morning dose on day of procedure only

• High-risk EGD: Polypectomy, EMR/ESD, dilation of strictures, therapy of varices, PEG, EUS with FNA, stent placement 1

  • Requires longer discontinuation period

Step 2: Assess Renal Function

Dabigatran is primarily renally cleared, making renal function crucial in determining discontinuation timing:

• Normal renal function (CrCl ≥50 mL/min):

  • Low-risk EGD: Omit morning dose on day of procedure
  • High-risk EGD: Last dose ≥48 hours before procedure 1

• Impaired renal function (CrCl 30-50 mL/min):

  • Low-risk EGD: Omit morning dose on day of procedure
  • High-risk EGD: Last dose 72 hours before procedure 1

• Severely impaired renal function (CrCl <30 mL/min):

  • Consult hematology for individualized management 1

Step 3: Consider Thrombotic Risk

For patients at high thrombotic risk (e.g., recent VTE <3 months, mechanical mitral valve, AF with mitral stenosis):

• Consider hematology consultation for bridging strategy if needed 1

Step 4: Post-Procedure Resumption

• Resume dabigatran 6-48 hours after procedure depending on bleeding risk:
  • Low bleeding risk: Resume ≥6 hours post-procedure
  • High bleeding risk: Resume 48 hours post-procedure 1

Important Clinical Considerations

1. No bridging anticoagulation needed: Unlike warfarin, dabigatran does not require bridging with LMWH due to its rapid onset of action 1

2. FDA label guidance: The FDA label recommends discontinuing dabigatran 1-2 days before invasive procedures for patients with normal renal function, and 3-5 days for those with impaired renal function (CrCl <50 mL/min) 2

3. Bleeding risk: The risk of delayed bleeding in diagnostic EGD with biopsy is low even with continued antithrombotic therapy 3, but high-risk procedures warrant appropriate discontinuation

4. Rapid onset/offset: Dabigatran reaches peak plasma concentration 1-2 hours after ingestion with a half-life of 12-14 hours in elderly patients 4, explaining why resumption should be carefully timed post-procedure

5. Avoid rapid discontinuation: Premature discontinuation without alternative anticoagulation increases thrombotic risk 2

Common Pitfalls to Avoid

• Pitfall #1: Using the same discontinuation protocol for all DOACs. Dabigatran has unique renal clearance properties requiring specific timing adjustments based on renal function.

• Pitfall #2: Failing to distinguish between diagnostic and therapeutic EGD procedures when determining discontinuation timing.

• Pitfall #3: Delaying resumption unnecessarily after low-risk procedures, which may increase thrombotic risk.

• Pitfall #4: Not accounting for deteriorating renal function, which may require longer discontinuation periods.

By following these evidence-based guidelines, you can minimize both bleeding and thrombotic risks when performing EGD in patients taking dabigatran.