Reversing Dabigatran Anticoagulation with Prothrombin Complex Concentrate versus Idarucizumab as Part of Multimodal Hemostatic Intervention in an Animal Model of Polytrauma

Background: Although idarucizumab is the preferred treatment for urgent dabigatran reversal, it is not always available. Prothrombin complex concentrate (PCC) may be an alternative and, with bleeding in trauma, additional hemostatic therapy may be required. The authors investigated multimodal treatment in a preclinical polytrauma model.

Methods: Dabigatran etexilate (30 mg/kg twice daily) was given orally to 45 male pigs for 3 days. On day 4, animals received a dabigatran infusion before blunt liver injury and bilateral femur fractures. After injury, animals were randomized 1: 1: 1: 1: 1 to receive placebo (control), tranexamic acid (TXA; 20 mg/kg) plus human fibrinogen concentrate (FCH; 80 mg/kg) (TXAFCH group), PCC (25 U/kg or 50 U/ kg) plus TXA plus FCH (PCC25 and PCC50 groups), or 60 mg/kg idarucizumab (IDA) plus TXA plus FCH (IDA group). Animals were monitored for 240 min after trauma, or until death.

Results: The degree of injury was similar in all animals before intervention. Control and TXA-FCH animals had the highest total postinjury blood loss (3,652 +/- 601 and 3,497 +/- 418 ml) and 100% mortality (mean survival time 96 and 109 min). Blood loss was significantly lower in the PCC50 (1,367 +/- 273 ml) and IDA (986 +/- 144 ml) groups, with 100% survival. Thrombin-antithrombin levels and thrombin generation were significantly elevated in the PCC50 group.

Conclusions: Idarucizumab may be considered the optimal treatment for emergency reversal of dabigatran anticoagulation. However, this study suggests that PCC may be similarly effective as idarucizumab and could therefore be valuable when idarucizumab is unavailable.