From the Guidelines
Dabigatran and edoxaban must be initiated with low molecular weight heparin (LMWH) before their use due to their pharmacokinetic properties, which require a bridging period to ensure continuous anticoagulation coverage. Unlike other direct oral anticoagulants (DOACs) such as rivaroxaban and apixaban, dabigatran and edoxaban have a delayed onset of action and cannot provide immediate anticoagulation 1. When treating conditions like venous thromboembolism (VTE) or pulmonary embolism (PE), immediate anticoagulation is necessary to prevent clot progression. The standard approach is to administer LMWH (such as enoxaparin) for at least 5 days and until the INR reaches 2.0 before transitioning to dabigatran or edoxaban. This bridging period ensures continuous anticoagulation coverage while waiting for the oral medication to reach therapeutic levels. The LMWH provides rapid anticoagulation through its anti-factor Xa activity, while the oral agent gradually builds up in the system.
Some key points to consider when using dabigatran and edoxaban include:
- Renal clearance accounts for approximately 50% of the total clearance of edoxaban, and 80% of total clearance of dabigatran after oral administration 1
- Clinical trial results indicated edoxaban to be noninferior to dalteparin with respect to the composite outcome of recurrent VTE or major bleeding 1
- The American Society of Hematology 2020 guidelines for management of venous thromboembolism recommend a conditional use of DOACs over VKAs as treatment for patients with a new diagnosis of VTE, considering variables such as renal and/or hepatic insufficiency, and patient preference for once- or twice-daily dosing 1
- For patients who will be treated with dabigatran or edoxaban, pretreatment with UFH or LMWH for up to 5 to 10 days is needed before switching to the DOAC 1
Overall, the use of LMWH before dabigatran and edoxaban is a crucial step in ensuring the safe and effective treatment of VTE and PE, and is supported by the latest clinical guidelines and evidence 1.
From the Research
Background on Dabigatran and Edoxaban
- Dabigatran and edoxaban are direct oral anticoagulants (DOACs) used for the prevention and treatment of venous thromboembolism (VTE) 2, 3.
- These medications have been shown to be effective in preventing VTE, but their use may require initial anticoagulation with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) 4, 3.
Role of LMWH in Dabigatran and Edoxaban Therapy
- LMWH is often used as a bridging anticoagulant before starting dabigatran or edoxaban therapy 2, 3.
- This is because LMWH has a more predictable anticoagulant effect and can be used to stabilize the patient's condition before transitioning to a DOAC 5, 4.
- The use of LMWH before dabigatran or edoxaban may help reduce the risk of bleeding complications and ensure a smooth transition to the DOAC 2, 3.
Clinical Evidence Supporting LMWH Use
- Studies have shown that LMWH is effective in preventing VTE and reducing the risk of bleeding complications 5, 4.
- The use of LMWH before dabigatran or edoxaban has been supported by clinical trials, which have demonstrated the safety and efficacy of this approach 2, 3.
- However, the specific requirements for LMWH use before dabigatran or edoxaban may vary depending on the individual patient's condition and the clinical context 6, 4.