Postponed absorption of dabigatran in a patient with paralytic ileus – difficulties in decision making on reversal agent (idarucizumab) use

According to the European Society of Cardiology (ESC) guidelines, non-vitamin K antagonist oral anticoagulants (NOACs) are first choice drugs in prevention of thromboembolic events among patients with atrial fibrillation (AF). According to our knowledge this was the only case of delayed absorption of dabigatran due to ileus. A 79-year-old woman with hypertension and a 1-year history of persistent AF treated with dabigatran (a direct thrombin inhibitor approved for the prevention of stroke in patients with non-valvular AF) 110 mg bid for two weeks. She was hospitalized due to acute abdominal pain, vomiting and diarrhea. Signs of acute embolism of abdominal aorta (paraparesis) were confirmed on contrast-enhanced computed tomography scan and she was qualified for emergency surgery. The use of idarucizumab, the specific reversal agent for dabigatran, was considered twice. This case shows that exposure to dabigatran may occur later in patient with acute ileus due to alterations in absorption than it can be expected in normal situation. Such patients should be carefully monitored for a significant rebound in anticoagulant activity.