Rapid functional decline after dabigatran toxicity in an elderly patient

Warfarin has been the gold standard of stroke prevention in patients with atrial fibrillation; however, it requires constant laboratory monitoring to maintain therapeutic levels and has significant interactions with food and medications. Newer oral anticoagulants, such as dabigatran, have gained widespread use for the prevention of stroke in elderly individuals with atrial fibrillation. Unlike warfarin, dabigatran does not require constant monitoring to administer and effectively create therapeutic anticoagulation. However, there are drawbacks and complications that are associated with its use, including the fact that elderly patients with multiple comorbidities and dynamic health statuses are often underrepresented in clinical trials involving dabigatran, the lack of a clinically available measure to monitor therapeutic effect, and the lack of a rapid reversal agent. The authors discuss these and other issues involving dabigatran use and present the case of an 83-year-old patient who experienced rapid functional decline preceded by a massive upper gastrointestinal hemorrhage due to dabigatran toxicity.