Perspective:

The following are 10 points to remember from this focused update on the use of dabigatran:

1. Dabigatran is a direct thrombin inhibitor that is primarily renally excreted.

2. Conversion of dabigatran to its active form is independent of cytochrome P-450, making dabigatran less susceptible to drug-drug and diet-drug interactions.

3. Dabigatran has a half-life of 12-17 hours and no specific antidote.

4. In a large randomized clinical trial (RE-LY), the annual risk of stroke/systemic emboli in patients with atrial fibrillation (AF) and ≥1 risk factor for stroke was 1.7% with warfarin.

5. Dabigatran, 150 mg twice daily, significantly reduced this risk by 34% with no increase in the risk of major bleeding.

6. In the RE-LY trial, dabigatran, 110 mg twice daily, was noninferior to warfarin for prevention of stroke/systemic emboli, and was associated with a 20% reduction in the risk of major bleeding.

7. Drug discontinuation rates for nonhemorrhagic side effects were higher with dabigatran than warfarin in the RE-LY trial.

8. Dabigatran should be used at a dose of 150 mg twice daily when the creatinine clearance is >30 ml/min, and 75 mg twice daily if the creatinine clearance is 15-30 ml/min.

9. Dabigatran is a useful alternative to warfarin for stroke prevention in patients with AF, ≥1 stroke risk factor, a creatinine clearance >15 ml/min, and no advanced liver disease.

10. The decision to use warfarin versus dabigatran for stroke prevention should be based on several factors, including side effects, compliance with twice-daily dosing, patient preference, cost, and stability of the international normalized ratio on warfarin.