title: Idarucizumab for Reversal of Dabigatran-Associated Bleeding: Misnomer or Miracle?
abstract: BACKGROUND
  The development of novel oral anticoagulants (NOACs) has revolutionized oral anticoagulation. Rapid incorporation of NOACs into general practice has heightened the demand for directed reversal agents. Idarucizumab is a targeted reversal agent that is approved for the urgent reversal of the anticoagulant effects of dabigatran. While it is a welcome addition to reversal strategies of dabigatran, a number of clinical questions exist regarding its place in therapy.
  
  
  OBJECTIVE
  We describe controversies regarding the use of idarucizumab therapy in patients with dabigatran-associated bleeding.
  
  
  CONCLUSIONS
  Although existing clinical studies show a rapid reversal of coagulation assays, these studies did not describe a corresponding improvement in mortality or rapid cessation of hemorrhage. It is questionable how heavily clinicians can rely upon the use of the surrogate endpoints in clinical studies, such as ecarin clotting time and dilute thrombin time. Another issue is whether patients exhibiting re-elevation of coagulation assays would benefit from an additional dose of idarucizumab, because this has not been studied. It is currently unclear if blood products must be given in addition to idarucizumab can be used as monotherapy.
  
  
  CONCLUSIONS
  The initial data suggest a definite role for idarucizumab in treatment of bleeding associated with dabigatran. As more clinical practice experience is gained with the agent and the remaining data on its use are released, clinicians can better guide the clinical use of idarucizumab. At present, there is currently not enough evidence for idarucizumab to be used as monotherapy.
authors.affiliation: St. Vincent's Medical Center Riverside, Jacksonville, Florida.
authors.forename: Luke
authors.initials: L
authors.lastname: Miller
authors.affiliation: University of Florida Health Jacksonville, Jacksonville, Florida.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Ferreira
authors.affiliation: St. Vincent's Medical Center Riverside, Jacksonville, Florida.
authors.forename: Calvin
authors.initials: C
authors.lastname: Tucker
mesh_terms: D000284:Administration, Oral; D061067:Antibodies, Monoclonal, Humanized / Q000494:pharmacology* / Q000627:therapeutic use; D000925:Anticoagulants / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use; D000069604:Dabigatran / Q000009:adverse effects* / Q000627:therapeutic use; D004336:Drug Antagonism; D006470:Hemorrhage / Q000188:drug therapy* / Q000209:etiology*; D006801:Humans
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D000925:Anticoagulants; C000594745:idarucizumab; D000069604:Dabigatran
keywords: bleeding; dabigatran; idarucizumab; oral anticoagulation; reversal strategies; toxicology