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Drug toxicity in the form of increased in drug level, altered coagulation parameters and bleeding: case report A 76-year-old man developed drug toxicity in the form of increased in drug level leading to altered coagulation parameters and bleeding during anticoagulant therapy with dabigatran-etexilate. Additionally, anticoagulant therapy with enoxaparin-sodium and heparin was considered to have caused altered coagulation parameters and bleeding. The man, who had been receiving regular anticoagulation with oral dabigatran-etexilate 110mg twice a day for prevention of stroke and systemic embolism because of non-valvular atrial fibrillation, received plasma exchange (PE) after treatment with immunoglobulins for severe Guillain-Barr´e-Strohl syndrome. Dabigatran-etexilate, which was discontinued in the evening before the day of lumbar puncture, was continued in the evening of hospital day 3. He had received oral dabigatran-etexilate 110mg-0-110mg on day 0 and day 4, 110-0-0 mg on day 1 and day 5, 0-0-110 mg on day 3 and none on day 2. Also, he received SC enoxaparin-sodium 60mg on day 5 and day 6, and he received IV heparin on day 7 [dosage not stated]. Shortly before the first PE on day 7, partial thromboplastin time (PTT) and INR were noted to be 69 seconds and 1.40, respectively. On the day 8 (1 day following PE), coagulation parameters changed, with PTT and INR of 166 seconds and >5.0, respectively, and a control later on that day confirmed the values of INR and PTT as >5.0 and >200 seconds, respectively. Thrombin time (TT) was noted to be >200 seconds. Dabigatran-etexilate level was elevated beyond the measurable value (>460 ng/mL). Also, he developed active signs of gastrointestinal bleeding and bleeding from catheter insertion sites. Therefore, on hospital day 7, the anticoagulants were discontinued, and the man received idarucizumab [Praxbind] and vitamin K after he underwent the second PE on day 8. Later on that day, no measurable level of dabigatran-etexilate was found, and INR, PTT and TT were noted to be stable at 1.90, 54 seconds and 15.5 seconds, respectively. However, after the third PE on the following day (day 9), dabigatran-etexilate levels again rapidly increased to 142 ng/mL, and the coagulation parameters changed, with INR, PTT and TT of 3.91, 107 seconds and >200 seconds, respectively. On the following day (day 10), dabigatran levels were observed to have been increasing, and he continued to exhibit active signs of bleeding from catheter insertion and gastrointestinal sites. Therefore, he was again treated with idarucizumab and vitamin K. Later on that day, measurable level of dabigatran-etexilate was not found to be decreased. Again after the fourth PE on the following day, the dabigatran- etexilate level was noted to be increased and TT was decreased. During this period, he did not show any active signs of bleeding. Therefore, idarucizumab was not administered. During the following days, dabigatran-etexilate levels slowly decreased while PE was stopped. He had excessive anticoagulation due t