Medically reviewed on August 12, 2018
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Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous [preservative free]:
Praxbind: 2.5 g/50 mL (50 mL)
Brand Names: U.S.
- Monoclonal Antibody
Idarucizumab, a specific reversal agent for dabigatran, is a humanized monoclonal antibody fragment (Fab) that binds specifically to dabigatran and its acylglucuronide metabolites with an affinity for dabigatran that is ~350 times greater than that of thrombin, and neutralizes the anticoagulant effect within minutes (Das 2015; Schiele 2013).
Vdss: 8.9 L
Biodegradation of small peptides and amino acids
Urine (~32% within the first 6 hours and <1% in the following 18 hours)
Onset of Action
Uncontrolled bleeding: Effects observed within minutes and hemostasis is restored at a median of 11.4 hours (Pollack 2015)
Duration of Action
Usually at least 24 hours
47 minutes (initial); 10.3 hours (terminal)
Special Populations: Renal Function Impairment
Total clearance was reduced and mean exposure (AUC) was increased in varying degrees of renal impairment. However, renal impairment did not impact the reversal effect of idarucizumab.
Use: Labeled Indications
Reversal of dabigatran: Reversal of the anticoagulant effects of dabigatran for emergency surgery/urgent procedures or in life-threatening or uncontrolled bleeding.
There are no contraindications listed in the manufacturer's labeling.
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to idarucizumab or any component of the formulation.
Reversal of dabigatran: IV: 5 g (administered as 2 separate 2.5 g doses no more than 15 minutes apart) (Pollack 2017). If coagulation parameters (eg, aPTT) re-elevate and clinically relevant bleeding occurs or if a second emergency surgery/urgent procedure is required and patient has elevated coagulation parameters, consider administration of an additional 5 g (limited data to support); in patients with dabigatran-associated intracranial hemorrhage, if refractory bleeding occurs after initial idarucizumab dose, consider re-dosing and/or hemodialysis (NCS/SCCM [Frontera 2016]).
Refer to adult dosing.
Dosing: Renal Impairment
No dosage adjustment necessary; renal impairment does not impact the reversal effect of idarucizumab.
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
IV: For IV use only. Do not shake. Prior to administration, flush preexisting IV line with sodium chloride 0.9%. Administer dose undiluted as an IV bolus either via syringe or as an infusion by hanging the vials. Do not mix with other drugs or administer any other infusion in the same IV line. Administer promptly once solution has been removed from vial. Infusion of each vial should take no longer than 5 to 10 minutes with the second vial of 2.5 g administered no later than 15 minutes after the end of the first 2.5 g vial (Pollack 2015 [protocol]).
Store intact vials at 2ºC to 8ºC (36ºF to 46ºF) in original packaging (to protect from light). Do not freeze. May store intact vials in the original packaging (to protect from light) at room temperature, 25°C (77°F), for up to 48 hours or up to 6 hours if exposed to light.
There are no known significant interactions.
1% to 10%:
Central nervous system: Headache (5%)
Gastrointestinal: Constipation (7%), nausea (5%)
Frequency not defined:
Hypersensitivity: Hypersensitivity reaction (including bronchospasm, fever, hyperventilation, pruritus, skin rash)
<1%, postmarketing, and/or case reports (Pollack 2015): Acute ischemic stroke, circulatory shock, deep vein thrombosis, intracardiac thrombus (left atrium), multiorgan failure, myocardial infarction (NSTEMI), pulmonary edema, pulmonary embolism, right heart failure, thromboembolic complications (Pollack 2017)
Concerns related to adverse effects:
• Hypersensitivity reactions: Although there is insufficient clinical experience with idarucizumab to fully evaluate the risk of hypersensitivity reactions, some reported adverse events possibly indicative of hypersensitivity reactions could not exclude a potential relationship. The risk of using idarucizumab in patients with known hypersensitivity (eg, anaphylactoid reaction) to idarucizumab or any of the components of the formulation should be evaluated cautiously against the potential benefit of emergency dabigatran reversal. Discontinue use if serious allergic reaction occurs (eg, anaphylaxis) and institute appropriate management.
• Thromboembolic risk: Since patients being treated with dabigatran, have underlying disease states predisposing them to thromboembolic events and reversing the effects of dabigatran will expose the patient to an elevated thrombotic risk; resume anticoagulant therapy as soon as it is appropriate. Dabigatran can be re-initiated 24 hours after idarucizumab administration if appropriate. In the phase 3 clinical trial, not all thromboembolic events that occurred reflected the underlying disease state being treated with dabigatran; adverse thromboembolic events included DVT, PE, atrial thrombus, NSTEMI, and ischemic stroke (Pollack 2015).
• Hereditary fructose intolerance: Formulation contains 4 grams of sorbitol as an excipient. Since IV administration of sorbitol in patients with hereditary fructose intolerance has been reported to result in serious reactions (eg, acute hepatic failure, hypoglycemia, hypophosphatemia, metabolic acidosis, uric acid elevations) including fatalities, consider the combined daily metabolic load of sorbitol/fructose from all sources including idarucizumab and other drugs containing sorbitol; minimum amount of sorbitol known to cause serious adverse reactions is unknown.
• Coagulation parameter re-elevation: Although the duration of effect typically lasts at least 24 hours, in the phase 3 clinical trial, coagulation parameters (eg, aPTT, TT, ecarin clotting time [not routinely available]) re-elevated in a limited number of patients between 12 and 24 hours after administration; some patients experienced re-elevation as early as 1 to 4 hours after administration which may have been due to high initial baseline dabigatran concentrations. If clinically relevant bleeding in conjunction with elevated coagulation parameters reoccurs following an idarucizumab 5 g dose, administration of a second dose should be considered (Pollack 2015; Pollack 2017).
• Incomplete reversal: Potential for incomplete reversal of dabigatran exists with idarucizumab. Case reports have described patients with very high initial serum dabigatran concentrations who experienced unsuccessful reversal of the anticoagulant effects of dabigatran after idarucizumab and required repeat doses; early detection of excessive dabigatran concentrations measured using the chromogenic ecarin clotting time assay or reflected as elevated coagulation parameters (ie, INR or thrombin time) is essential (Steele 2017).
Monitor for re-elevation of coagulation parameters (eg, aPTT); signs/symptoms of clinically relevant bleeding and thromboembolic events.
In patients overdosed with dabigatran, consider the following monitoring schedule (Alikhan 2014): Baseline aPTT (at presentation), repeat at 2 hours postexposure (if exposure time is known) or post-presentation (if exposure time is unknown) and every 12 hours thereafter until aPTT returns to normal.
Animal reproduction studies have not been conducted.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience headache, nausea, or constipation. Have patient report immediately to prescriber signs of blood clots (numbness or weakness on one side of the body; pain, redness, tenderness, warmth, or swelling in the arms or legs; change in color of an arm or leg; angina; shortness of breath; tachycardia; or coughing up blood), bleeding, shortness of breath, or fast breathing (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
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- Drug class: anticoagulant reversal agents
Other brands: Praxbind