• John W Eikelboom, Joanne van Ryn, Paul Reilly, Elaine M Hylek, Amelie Elsaesser, Stephan Glund, Charles V Pollack, and Jeffrey I Weitz.
• Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada. Electronic address: eikelbj@mcmaster.ca.
• J. Am. Coll. Cardiol. 2019 Oct 8; 74 (14): 1760-1768.

BackgroundDabigatran and idarucizumab, its reversal agent, are renally cleared.ObjectivesThe purpose of this study was to determine the extent of reversal and outcomes according to baseline renal function in dabigatran-treated nondialysis patients receiving idarucizumab.MethodsIn 503 patients in RE-VERSE AD (Reversal of Effects of Idarucizumab in Patients on Active Dabigatran), the extent of dabigatran reversal and clinical outcomes were compared according to baseline renal function (creatinine clearance: normal ≥80, mild 50 to <80, moderate 30 to <50, and severe <30 ml/min).ResultsCompared with patients with normal renal function, those with impaired renal function were older, were more often women, and had lower body mass indexes, more comorbidities, higher CHADS2 scores, and higher dabigatran plasma levels despite more frequent use of lower-dose dabigatran regimens. Regardless of renal function, median reversal measured by dilute thrombin time was 100% within 4 h of idarucizumab administration, and over 98% of patients achieved this with corresponding undetectable levels of unbound dabigatran. By 12 or 24 h, 56% of patients with severe, 29.1% with moderate, and 9.2% with mild renal impairment had dabigatran levels >20 ng/ml compared with 8.3% of patients with normal renal function at baseline. Time to cessation of bleeding and the proportion with normal hemostasis with procedures were similar regardless of renal function, but patients with severe renal impairment had higher 30- and 90-day mortality rates.ConclusionsIdarucizumab completely reverses dabigatran in >98% of patients regardless of renal function. Although re-elevation of dabigatran levels within 12 to 24 h is more common with renal impairment, the time to bleeding cessation and the extent of hemostasis during procedures are similar. (Reversal of Dabigatran Anticoagulant Effect With Idarucizumab; NCT02104947).Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.

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