Dabigatran for Stroke Prevention in Patients with TIA or Ischaemic Stroke and Atrial Fibrillation: Practical Apects

Dabigatran is the first direct inhibitor of thrombin that has been approved for primary and secondary stroke prevention in patients with atrial fibrillation. The RELY Study showed that dabigatran given at a dose of 110 mg BID was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin (INR target 2.0-3.0), as well as lower rates of major haemorrhage. Dabigatran administered at a dose of 150 mg BID was significantly more effective compared to warfarin but showed a similar rate of major haemorrhage. Both dosages resulted in an approximately 70% reduction of intracerebral haemorrhages. The dosage of 110 mg BID should be preferably used in patients >80 years and with a higher bleeding risk. Treatment with dabigatran can be initiated immediately in patients with a TIA, 3-5 days after stroke onset in patients with minor stroke, and 10-14 days after stroke onset in patients with severe stroke. The anticoagulant effect of dabigatran is established within hours. Dabigatran 100 mg BID or 150 mg BID is contraindicated in patients with severe renal impairment (creatinine clearance <30 mL/min). Patients who have been on dabigatran during the preceding 48 h should not be treated with systemic thrombolysis. The activated partial thromboplastin time may be prolonged under dabigatran. Intracerebral bleeding in patients taking dabigatran should be treated with prothrombin complex concentrates, fresh frozen plasma, or recombinant factor VII. The combination of dabigatran and platelet inhibitors increases the bleeding risk and is therefore not recommended in patients with stable coronary artery disease. The most common side effect of dabigatran is dyspepsia.