rTPA USE IN STROKE AND NEW ANTICOAGULANTS.
Currently available new anticoagulant drugs (NAC) or direct oral anticoagulant (DOAC) have the indication for the prevention of stroke in atrial fibrillation and treatment of venous thromboembolism. Dabigatran (Pradaxa) is a direct inhibitor of coagulation II-factor, rivaroxaban (Xarelto®) and apixaban (Eliquis®) are direct inhibitors of factor-X.
Dabigatran have an antidote (Praxbind©) that could reverse effect of dabigran in case of haemorrhage or add rtPA in case of ischemic stroke with thrombus far away from segments candidates to endovascular treatment.
These drugs do not require monitoring, and clotting times that can be performed in the laboratory of emergency (PT, APTT) are very specific and sensitive, but can be useful to provide guidance on the anticoagulant effect of these. Therefore it will be very important to find out the time of administration of the last dose of the drug and the patient renal function to decide whether thrombolysis can be performed with rtPA.
Average life (hours) Elimination
Dabigatran (Pradaxa®) 12-14 80% renal
Rivaroxaban (Xarelto®) 33% renal 9-13
Apixaban (Eliquis®) 8-15 25% renal
IT MIGHT CONSIDER POSSIBILITY OF THROMBOLISYS:
1 If large vessel is occluded alternative treatments such as thrombectomy msut be consider.
2 Evaluate dose, when was the last intake, emergency clotting time test s(PT and APTT) and renal function.
PATIENT WIHT DABIGATRAN (PRADAXA)
Drug administered as thromboembolism prevention in atrial fibrillation at a dose 110 mg / 12 h or 150 mg / 12h
-Less than 24 hours of last dose: DO NOT GIVE rtPA.
–More than 24 hours and normal renal function if last dose: Check PT and APTT (may slightly increased time of APTT)
–If coagulation levels are minimally altered it is still under anticoagulant effect: NOT TREAT WITH rtPA
–If normal PT and APTT rtPA: may be given if no other option
therapeutic.(Be careful and check other criterias)
In renal insufficiency the time required for the anticoagulant effect of dabigatran decrease to safe levels slowly. Depending on the creatinine clearance, the following table shows the time that must pass between the last dose and the procedure for it to be safe.
Renal function (CrCl mL / min) Average life (Hours) Last dose of dabigatran:
> 60: 13-24 hours
30-60: 18 -48 hours
< 30: 3-5 days(diálisis
PATIENT WITH RIVAROXABAN (XARELTO). 20 mg / 24 (exceptionally doses are 15mg / 12h anticoagulation for acute thrombosis DVT)
– Less than 24 hours after the last dose: DO NOT GIVE rtPA.
– More than 24 hours after reviewing PT and APTT (TP clotting time)
If you are minimally altered (rtPA not administer)
If you are regular rtPA may be given if there is no other treatment option.
PATIENT WITH APIXABAN. 5mg/12 or 2.5 mg/12. The same recommendation as rivaroxaban.