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Dabigatran: rational dose individualisation and
monitoring guidance is needed
Stephen B Duffull, Daniel F B Wright, Hesham S Al-Sallami,
Paul J Zufferey, James M Faed
Dabigatran is an orally-active direct thrombin inhibitor
currently licensed for use in non-valvular atrial fibrillation and for the
prevention of venous thromboembolism following joint replacement surgery. It is
marketed in New Zealand under the brand name
Pradaxa® and was listed in the
Pharmaceutical Schedule without Special Authority in July 2011. Whilst we
believe that the availability of this drug will provide more flexibility for the
prescriber, and may lead to improved outcomes for some patients, we have major
concerns about the lack of rational advice on dosing and monitoring,
particularly for patients at high risk of bleeding.
Current dosing guidance for dabigatranThe current dosing advice for prescribers is puzzling. The
New Zealand datasheet states that all patients get a fixed dose unless (1) they
have atrial fibrillation and are over 80 years old, or, (2) if they have had
orthopaedic surgery and have impaired renal
function.1 No comment is made as to why the
suggested dose reductions for age and renal impairment do not apply equally to
both indications. This guidance seems to fly in the face of reason.
Drugs that are cleared renally, such as dabigatran, are
reliant on glomerular filtration rate (GFR) for elimination. A normal GFR may be
in the order of about 100 mL/min. If the patient has a GFR of half or one-third
normal (e.g. 30–50 mL/min) the clearance of the drug will also be reduced
and plasma concentrations will increase proportionately. A dose reduction is
therefore required to normalise drug exposure and reduce the risk of adverse
effects.
There is a paucity of independent prescribing guidance for
dabigatran. The recent bulletin from the Best Practice Advocacy Centre (BPAC) is
a welcome and thorough overview of dabigatran for primary care practitioners but
falls short when it comes to specific advice about dosing. Rather, BPAC
advocates that prescribers take a ‘cautious approach’, particularly
when prescribing for patients at high risk of bleeds such as those with renal
impairment.2 This leaves the practitioner with
little practical guidance with which to meet the needs of individual patients.
Consider, for example, the hypothetical case of a
79-year-old female with atrial fibrillation who has a lean mass of 50 kg and a
normal serum creatinine of 110 μmol/L. Her estimated creatinine clearance
calculated by the Cockcroft and Gault formula would be 33 mL/min. This patient
would clearly be at risk of increased drug exposure and bleeding if a fixed dose
were given, a situation that would no doubt be recognised by a cautious
prescriber. However, the fact remains that the dosing guidance in this situation
is lacking and contradictory.
In the absence of a validated means of monitoring the
effectiveness and safety of therapy the physician is left guessing as to the
best course of action. If the patient had been post-orthopaedic surgery, then
the dose would be reduced according to the recommendations in the datasheet
without question. However since the patient has atrial fibrillation the
manufacturer’s guidance suggests that it is perfectly reasonable to
continue the dose at 150 mg twice daily without adjustment.
The need for dose individualisationAs with any anticoagulant, the use of dabigatran carries a
risk of bleeding.3 Major bleeding is an
independent predictor of death and is associated with increased cost and longer
duration of hospital stay.4,5 Arguably, there
is a fine line between the magnitude of anticoagulation required to prevent
clots in susceptible patients and that which is sufficient to cause bleeding,
especially in a patient population where a variety of vascular disorders are
common. This is independent of the drug itself but relates to the innate
complexity and sensitivity of the coagulation network, which is the target for
anticoagulant action.
In short, we suggest that all anticoagulants used in
therapeutic doses will have a narrow therapeutic range and will require
selective monitoring to ensure optimal effectiveness and the prevention of side
effects. In addition, analysis of the coagulation system (based on Wajima et
al6) suggests that there may be less natural
dampening of the coagulation system with anticoagulants that target the later
stages of coagulation. Hence, the anticoagulant effects of drugs like dabigatran
that act close to the final stage of clot formation will, in theory, be more
sensitive to the prescribed dosing regimen and to inherent variability in the
dose-concentration relationship (pharmacokinetics).
When dabigatran was introduced into the New Zealand market
the media release from Pharmac claimed “... [dabigatran] is literally a
game-changer and demonstrates PHARMAC’s desire to move relatively swiftly
to fund genuinely innovative medicines”.7
Although the spirit of the statement is appropriate, the suggestion that
introducing a new drug is all that it takes to change the game is misleading.
Individualisation of existing medicines has often been shown
to be quantitatively more important than the introduction of a new medicine. For
instance, an individualised regimen of enoxaparin treatment, based on renal
function and body composition, resulted in a number needed to treat (NNT) of 8
patients to reduce bleeding events when compared to conventional weight-adjusted
dosing.8
This is a very favourable number when compared to many new
interventions. For example, simvastatin was found to have an NNT for one year of
167 for preventing all cardiovascular events in the Scandinavian Simvastatin
Survivial Study (4S).9 We therefore contend
that the act of introducing a new anticoagulant will not necessarily change the
game without knowledge of how best to individualise its use.
So why would dabigatran be considered a games changer?
Perhaps this is because it is seen as a replacement for warfarin, with its
requisite INR monitoring and dose adjustments? If so, we query whether
dabigatran will ultimately prove to be all that different from warfarin and
whether dose individualisation and selected anticoagulation monitoring will
eventually prove important for safe prescribing. If so, the monitoring required
will need to be targeted to clinical situations that are more likely to be
associated with bleeding or clotting.
Is dabigatran a better choice than warfarin?Warfarin acts by inhibiting the formation of vitamin K
dependant clotting factors (II, VII, IX and X). Daily dose requirements are
highly variable between patients, ranging from < 1 mg/day to > 10
mg/day.10 This large variability is often
interpreted as a leading problem with warfarin therapy. However it also
indicates that doses are being successfully adjusted to meet the needs of
individual patients.
Herein lies the dichotomy between the desire for
simplicity—one dose fits all, and the needs of our patients, where doses
should be optimised to meet their specific requirements. Indeed from a
standpoint of optimising care the warfarin dosing model is an excellent example
of success. It is apparent that services that are set up for this purpose
(individualising warfarin dosing) achieve better health outcomes for
patients.11,12
A related problem with warfarin is that its metabolic
clearance has been found to vary between individuals due to genetic
polymorphisms in cytochrome P450 enzymes (largely
CYP2C9).10,13 It also interacts with vitamin K
in the diet and vitamin K stores in the body resulting in variability in
response. However we can measure a patient’s response to warfarin with the
INR, an inexpensive test that can now be performed in the clinic or at home
using a portable device.14
INR results capture information about the patient’s
individual response to warfarin and allow for rational dose adjustments. We
could also measure a patient’s genotype to help predict a starting dose
for warfarin,13 although this is not routinely
performed in New Zealand and will only identify variability that arises from
genetic differences between individuals.
Another issue is that warfarin may cause excessive bleeding
after dosing that is higher than required and occasionally at the intended dose.
This can be reversed by either withholding the drug or, if required promptly,
administering vitamin K, and the addition of Prothrombinex-VF if urgent
correction is required.
Unlike warfarin, it is claimed that dabigatran has a
predictable pharmacokinetic and pharmacodynamic profile which allows for the use
of fixed doses.15 Yet, the variability in
dabigatran clearance, the pharmacokinetic parameter most important for
determining the maintenance dose, has been reported to be in the order of 50 %
(coefficient of variation across the
population)16 which is similar to the
variability observed for warfarin clearance of 30–50
%.17,18
On this basis alone dabigatran exposure is not more
predictable than warfarin. Indeed it might therefore be argued that if one dose
does not fit all for warfarin then why would we expect this to be the case with
dabigatran? As there is a correlation between dabigatran blood concentrations
and efficacy and safety outcomes,19 unpredicted
high or low blood concentrations could increase the risk of adverse
events.
There is published evidence to indicate that dabigatran
exposure differs predictably between individuals. The manufacturer reports that
drug exposure was 1.5–6.3-fold higher in those with renal impairment
compared to healthy subjects.20 Exposure to
dabigatran may also be altered in patients with low body weight. The
Pradaxa® datasheet states that drug
exposure was about 40–50 % higher in female patients in primary VTE
prevention studies.1 In atrial fibrillation
patients, females had an average 30 % higher trough post-dose concentration than
male patients. We believe that these sex differences may relate to differences
in body composition (e.g. lean body weight) between males and females.
Therefore, dabigatran exposure in individuals at the extremes of body weight
needs to be defined and evaluated.
Dabigatran is poorly absorbed orally because it is a
substrate for P-glycoprotein,21 an efflux
transporter responsible for limiting systemic xenobiotic exposure by pumping
drug back into the gut. There are currently over 100 known polymorphic variants
of the gene that codes for P-glycoprotein
(ABCB1)22 and it is not clear what
impact different genotypes will have on efflux function in many cases.
By contrast, the impact of altered hepatic enzyme activity
on warfarin exposure is well understood and can be measured by determining the
patients genotype.23 In addition, several drugs
and drug classes have been found to inhibit
P-glycoprotein22 24 such as amiodarone,
atorvastatin, felodipine, verapamil, macrolides, some antifungals as well as
foods such as with grapefruit and other citrus
juices.25 Ingestion of these drugs and foods
may result in elevated plasma dabigatran concentrations and an increased risk of
bleeding.
Monitoring dabigatran therapyDabigatran shows varied effects on individual coagulation
screening tests. There is limited sensitivity of the PT/INR, better sensitivity,
though non-linearity at lower concentrations, of the aPTT, and marked
sensitivity of the thrombin clotting time
(TT).15 The Ecarin clotting time appears to be
a slightly more sensitive test but availability is currently limited in New
Zealand. Data suggests that three factors affect the test results: drug
concentration, the patient’s intrinsic coagulation kinetics and the
variability of the screening test(s).15 This
situation is similar to variation in the INR testing of warfarin effect, despite
strenuous international efforts to standardise the test results. Further
research to validate a clotting time test for monitoring dabigatran effect is
required. Research is also needed to establish guidelines for monitoring.
In the absence of a validated anticoagulation measure for
dabigatran, the best widely available clotting time test for monitoring and dose
individualisation is probably the aPTT. Published data indicate that
prolongation of the aPTT at peak drug concentration (i.e. 2–4 hours post
dose) will be around 1.9x, ranging from 1.6x–2.2x or 46–65s where
the reference range is 24–34s (note that values will differ where the
reference range differs).15 This may be useful
in assessing peak dose effects to confirm the dose selected, particularly in low
weight patients and in those whom P-glycoprotein function is known or suspected
to be abnormal. Trough aPTT values (i.e. just before the next dose) may be
useful for detecting significant drug accumulation in a renally impaired patient
and where low body weight or metabolic factors lead to higher values. Trough
aPTT values appear to be in the range 34–45s (reference range
24–34s) but this needs confirmation. The sensitivity of the aPTT for
trough measurements will be poor at low dabigatran concentrations but can be
detected by the thrombin clotting time (TT).
We suggest that monitoring may be appropriate in the
following situations: initial dose individualisation in patients at risk of
increased drug exposure and bleeding (aPTT), patients with deteriorating renal
function (aPTT), and where a patient requires urgent/emergency surgery to detect
the absence of residual drug (TT). Note that trough and peak monitoring will be
time-dependent and when used will require patients to attend for sample
collection at the required time pre- or post-dose.
If a patient receives sustained excessive dosing of
dabigatran and experiences a bleed there is currently no antidote. Efforts to
produce an inhibitor of dabigatran have been reported using monoclonal antibody
technology but are still at an early stage of
development.26 Other approaches to managing
bleeding rely on non-specific and local measures as noted in the Pharmac
guidance document for managing bleeds.27
Haematologist advice should be sought for reversing the effect of dabigatran for
acute surgery or in the event of acute bleeding.
The fact that the monitoring of dabigatran therapy is
currently not recommended should not be
misinterpreted to mean that monitoring is not required. Although the
published trial data for dabigatran indicates similar or lower bleeding rates in
the selected trial participants compared with warfarin, this is not enough to
claim that monitoring is not required. It is well established in medical ethics
that where it is possible to reduce the risk of bleeding or thrombosis as a
result of inappropriate dosing, by taking reasonable actions, these actions
should be taken.
ConclusionsWe believe there is a clear need for rational dose
individualisation and monitoring guidance with dabigatran, particularly for
patients at higher risk of bleeding. This would include the elderly, those at
the extremes of body weight or with renal impairment and/or on drugs with
potential interactions. Patients with moderate renal impairment should receive a
smaller daily dose and, based on our current knowledge, the drug should be
avoided in those with severe renal impairment (calculated Cockroft-Gault GFR
<30 ml/min).
There are some important questions that arise from the
enthusiastic introduction of dabigatran. Is it reasonable to expect that any new
anticoagulant could be safely prescribed at a fixed dose with no anticoagulation
monitoring? In our opinion, no. Indeed, we would not expect any anticoagulant
used in therapeutic doses to achieve a high level of safety.
As noted, this is because of the thin line that exists
between therapeutic anticoagulation and the risk of bleeding. Therefore, we
propose that all new anticoagulants should be backed up by independent and
relevant drug information at their time of launch and the need to individualise
dosage should be the expectation. Is dabigatran a breakthrough in
anticoagulation? In our opinion, yes. Dabigatran is a novel anticoagulant and we
believe if used appropriately will add to our ability to meet the needs of our
patients. Dabigatran is not, however, a game changer. We should not
discard warfarin simply on the grounds that it may be more difficult to use in
favour of a drug where: reversibility in the presence of acute bleeding has not
been established, the drug has wide variability in its exposure from any given
dose, and is a candidate for many drug interactions.
We contend that a wide range of prescribed dabigatran doses
across the population would be a good indicator of our success in selecting
doses to meet our individual patients’ needs. If we do not monitor
anticoagulation effects how do we really know we are meeting our patients’
needs? A blindfold is not what the best dressed practitioner should be
wearing.
Competing interests: James Faed is a
paid member of the Committee of Haematologists convened by PHARMAC to advise on
the release of dabigatran in New Zealand.
Author information: Stephen Duffull, Chair
of Clinical Pharmacy, School of Pharmacy, University of Otago, Dunedin, New
Zealand; Dan Wright, Lecturer in Clinical Pharmacy, School of Pharmacy,
University of Otago, Dunedin, New Zealand; Hesham Al-Sallami, Lecturer in
Clinical Pharmacy; School of Pharmacy, University of Otago, Dunedin, New
Zealand; Paul Zufferey, Anaesthetist, Thrombosis Research Group, University Jean
Monnet, Saint-Etienne, France; Jim Faed, Haematologist, Dept of Pathology,
Dunedin School of Medicine, University of Otago, Dunedin
Correspondence: Professor Stephen Duffull,
School of Pharmacy, University of Otago, PO Box 56, Dunedin 9054, New Zealand.
Fax: + 64 (0)3 4797034; email: stephen.duffull@otago.ac.nz
References:
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