Can I directly switch to dabigatran (Pradaxa) from another anticoagulant?

Switching to Dabigatran from Other Anticoagulants

Dabigatran can be directly switched from other anticoagulants, but specific timing protocols must be followed based on the previous anticoagulant to ensure continuous anticoagulation without increased bleeding risk. 1

Switching Protocols by Previous Anticoagulant

From Warfarin to Dabigatran

• Discontinue warfarin
• Start dabigatran when INR is <2.0 2
• For patients with mechanical heart valves: Do NOT switch to dabigatran (contraindicated) 2, 1

From LMWH to Dabigatran

• Start dabigatran 0-2 hours before the next scheduled dose of LMWH 1
• Alternatively, start dabigatran at the time of discontinuation of continuous LMWH treatment (e.g., intravenous unfractionated heparin) 2

From Other DOACs to Dabigatran

• Discontinue current DOAC
• Start dabigatran at the time the next dose of the other DOAC would be due 1
• No overlap period is required 2

From Parenteral Anticoagulants to Dabigatran for VTE Treatment

• Dabigatran requires 5-10 days of initial parenteral anticoagulation before switching 2
• Unlike rivaroxaban and apixaban which can be started immediately without parenteral lead-in 2

Dosing Considerations

Standard Dosing

• Non-valvular atrial fibrillation: 150 mg twice daily (for CrCl >30 mL/min) 1
• DVT/PE treatment: 150 mg twice daily after 5-10 days of parenteral anticoagulation 1

Dose Adjustments

• For CrCl 15-30 mL/min: 75 mg twice daily 1
• For patients at high bleeding risk (HAS-BLED ≥3): Consider 110 mg twice daily 2
• Dabigatran is contraindicated in patients with CrCl <15 mL/min 2, 1

Special Considerations

Renal Function

• Dabigatran is primarily eliminated by the kidneys 3
• Check renal function before switching 2
• Longer discontinuation time needed before procedures in patients with reduced renal function 1

Drug Interactions

• Avoid concomitant P-glycoprotein inducers 1
• Reduce dose or avoid with P-glycoprotein inhibitors in patients with CrCl 30-50 mL/min 1
• P-glycoprotein inhibitors not recommended in patients with CrCl <30 mL/min 1

Cancer Patients

• LMWH generally preferred over dabigatran for cancer-associated thrombosis, especially with gastric or gastroesophageal lesions 2
• If LMWH not appropriate, dabigatran can be used after 5 days of parenteral anticoagulation 2

Perioperative Management

Temporary Discontinuation for Procedures

• CrCl ≥50 mL/min: Discontinue 1-2 days before procedure 1
• CrCl <50 mL/min: Discontinue 3-5 days before procedure 1
• Consider longer times for major surgery, spinal procedures 1
• Restart as soon as medically appropriate 1

Monitoring and Follow-up

• Unlike warfarin, routine coagulation monitoring is not required 4
• No specific antidote was available until recently (idarucizumab now available for emergency reversal) 1
• Monitor for signs of bleeding, especially gastrointestinal symptoms 1, 5
• Dyspepsia is more common with dabigatran than with warfarin 5

Contraindications for Switching to Dabigatran

• Active pathological bleeding 1
• Mechanical heart valves 2, 1
• Severe renal impairment (CrCl <15 mL/min) 2, 1
• History of serious hypersensitivity to dabigatran 1

Following these protocols ensures safe and effective transition between anticoagulants while maintaining appropriate anticoagulation coverage and minimizing bleeding risk.