Sir, we are in agreement with Syyed (BDJ 2014;217: 623–625) and Scully (BDJ 2015;219: 515) regarding the limitations associated with dabigatran, and appreciate the early discussion surrounding idarucizumab posed by Curto (BDJ 2016;220: 278). However, since these letters, there have been updates surrounding idarucizumab reversing dabigatran in emergency settings.
Dabigatran is one of three currently approved novel oral anti-coagulants (NOACs). Dabigatran is currently licensed for prevention of venous thromboembolism after hip or knee replacement surgery, prevention of stroke and systemic embolism in atrial fibrillation and treatment of thrombo-embolic disease. Although dabigatran is associated with less serious bleeding than warfarin,1 life-threatening bleeding events can still occur. The SDCEP have attempted to create a guideline for dental surgeons to help manage patients on NOACs prior to low or high risk surgery on the basis of low quality evidence. However, these guidelines were largely conservative, encouraging patients to continue taking dabigatran for low risk surgeries and omit a dose for high risk surgeries.
Recent evidence regarding the efficacy of iduracizumab, a reversal agent for dabigatran, has stimulated debate as to its usefulness. A phase 1 trial initially showed the drug was able to reverse the effects of dabigatran with limited side effects.2 This was followed by the phase 3 RE-VERSE AD trial3 which demonstrated iduracizumab's ability to normalise clotting time in 88-98% of participants taking dabigatran prior to urgent surgery. Since this trial several case reports4,5,6 have matched the same results with safe instant reversal of dabigatran, as the ongoing REVERSE-AD trial7 continues to show promising, similar results. As the medication is still largely novel, the trials regarding efficacy and long-term risks are ongoing. However, current evidence suggests iduracizumab is a safe and efficacious method of dabigatran reversal with further research required.
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Chandan, J., Thomas, T. & Baryah, H. Anticoagulants: Updates on idarucizumab. Br Dent J 222, 140–141 (2017). https://doi.org/10.1038/sj.bdj.2017.95
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DOI: https://doi.org/10.1038/sj.bdj.2017.95