Ischemic stroke and intestinal bleeding under dabigatran in metabolic myopathy

Objectives: The subsequent occurrence of an ischemic thromboembolic event and a bleeding shortly after discontinuation of dabigatran has not been published.

Case report: In an 89-year-old female with atrial fibrillation dabigatran had been started 11 days before admission, following a transitory ischemic attack. Phenprocoumon had been stopped 1 month earlier because of a hematoma after a fall. Although dabigatran was discontinued already on hospital day 1, she experienced an intestinal bleeding on hospital day three and an ischemic stroke on hospital day 6. As blood coagulation parameters were still abnormal on hospital day 2, intestinal bleeding was attributed to the prolonged antithrombotic effect or the interaction of dabigatran with the comedication. Stroke was attributed to the absence of a sufficient antithrombotic effect or a rebound effect 5 days after discontinuation of dabigatran. Clinical neurological examination additionally suggested a neuromuscular disorder.

Conclusions: Ischemic stroke and intestinal bleeding may consecutively occur shortly after stopping dabigatran. Coagulation parameters may remain abnormal even 2 days after discontinuation of dabigatran. Dabigatran should be applied with caution in elderly patients with renal insufficiency who also take drugs, which enhance the absorption of dabigatran.