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

From the Guidelines

Stopping Dabigatran before Colonoscopy or Polypectomy

Dabigatran should be stopped 72 hours before colonoscopy or polypectomy in patients with impaired renal function (CrCl 30-50 mL/min) and normal liver function tests. This recommendation is based on the pharmacokinetic properties of dabigatran and the need to minimize the risk of bleeding during the procedure.

Rationale

• The half-life of dabigatran is 14-17 hours, and 75-80% of its clearance is renal 1.
• In patients with impaired renal function, the clearance of dabigatran is reduced, and the half-life is prolonged 1.
• The British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guidelines recommend stopping dabigatran 72 hours before high-risk endoscopic procedures in patients with CrCl 30-50 mL/min 1.
• The American College of Chest Physicians clinical practice guideline suggests stopping dabigatran 1-4 days before elective surgery/procedure, depending on the patient's renal function and the procedure's bleed risk 1.

Key Points

• Colonoscopy with polypectomy is considered a high-bleed-risk procedure 1.
• Dabigatran should be stopped 72 hours before the procedure to minimize the risk of bleeding 1.
• Renal function should be assessed before stopping dabigatran, and the decision to stop the medication should be individualized based on the patient's renal function and the procedure's bleed risk 1.
• The patient's liver function tests are normal, which does not affect the decision to stop dabigatran 1.

From the FDA Drug Label

If possible, discontinue dabigatran etexilate capsules in adults 1 to 2 days (CrCl ≥50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before invasive or surgical procedures because of the increased risk of bleeding Consider longer times for patients undergoing major surgery, spinal puncture, or placement of a spinal or epidural catheter or port, in whom complete hemostasis may be required

For a patient with impaired renal function and normal liver function tests undergoing colonoscopy or polypectomy, discontinuation of dabigatran should be considered as follows:

• For patients with CrCl ≥50 mL/min: discontinue dabigatran 1 to 2 days before the procedure.
• For patients with CrCl <50 mL/min: discontinue dabigatran 3 to 5 days before the procedure. It is essential to weigh the risk of bleeding against the urgency of the intervention and consider using a specific reversal agent if needed 2.

From the Research

Dabigatran Discontinuation Before Colonoscopy or Polypectomy

• In patients with normal renal function, discontinuation of dabigatran etexilate 24 hours before standard elective surgery is sufficient to normalize the bleeding risk 3.
• However, for patients with renal impairment, the recommended duration of discontinuation is prolonged 3.
• The exact duration of dabigatran discontinuation before colonoscopy or polypectomy in patients with impaired renal function is not specified in the provided studies.
• A study on dabigatran reversal with idarucizumab in patients with renal impairment found that idarucizumab completely reverses dabigatran in >98% of patients regardless of renal function, but re-elevation of dabigatran levels within 12 to 24 hours is more common with renal impairment 4.
• Another study derived a dosing regimen for dabigatran in patients with severe renal impairment, recommending a twice-daily regimen of 75 mg 5.

Bleeding Risk and Dabigatran

• The risk of postpolypectomy bleeding (PPB) is higher in patients receiving direct oral anticoagulants (DOACs), including dabigatran, compared to those without anticoagulation or receiving warfarin 6.
• Even with 24-hour withdrawal before polypectomy, DOACs can significantly raise the risk of PPB 6.
• Dabigatran showed a lower PPB rate than warfarin in a subgroup analysis 6.

Management of Bleeding

• In cases of bleeding, treatment should be based on the severity and localization of the bleeding 3.
• For minor bleedings, a delay in the administration of the next dabigatran etexilate dose is recommended, with the length of the delay based on the patient's individual thromboembolic risk 3.
• In cases of moderate or major bleedings, the main focus should be on stabilizing the circulation using fluids and blood products, and local treatment of the lesion if identified 3.
• Hemodialysis can effectively remove dabigatran from the circulation, especially in patients with impaired kidney function 7.