Fatality in a patient treated with dabigatran

A 66-year-old woman developed acute diarrhea and vomiting and was admitted 4 days later in shock (70/40 mm Hg) and acute renal failure (serum creatinine, 6.71 mg/dL). She had hypertensive and rheumatic heart disease and mitral valve replacement. After warfarine failure and enoxaparin hypersensitivity, dabigatran was started (150 mg twice a day) when estimated glomerular filtration rate (eGFR) was 72 mL/min. Oral mucosal bleeding was noted on intubation, and laboratory tests showed prothrombin time (PT) less than 8%; international normalized ratio, no clot; activated partial thromboplastin time of 122 seconds; and no evidence of sepsis. No treatment was effective, and she died on the first hospital day bleeding from all mucosal surfaces and puncture sites. Physicians need to be aware and patients need to be better informed of not uncommon contingencies that may acutely decrease glomerular filtration rate and increase the risk of bleeding with dabigatran before opting for dabigatran as an anticoagulant treatment.