Direct oral thrombin inhibitor dabigatran etexilate is able to controle chronic disseminated intravasal coagulation: a case report

W. Korte, L. Graf (1St. Gallen, Switzerland)

Acquired problems and alterations of coagulation
Date: 17.02.2017,
Time: 17:15 - 18:15

Objective: The Kasabach Merritt syndrome (KMS) consists of consumptive coagulopathy due to vascular tumors (often giant hemangioma). Consumptive coagulopathy often progresses to disseminated intravascular coagulation (DIC) rendering the patient at risk for both bleeding and thrombotic events.

Methods: We report on a 63-year-old female patient with a known KMS. She had a history of chronic DIC with severe hyperfibrinolysis that was successfully controlled with low molecular weight heparins (LMWH; dalteparin 7500U s.c. qd) and tranexamic acid (500mg bid) for years. Concomitantly, the patient suffered from chronic hepatitis C infection leading to liver cirrhosis (CHILD C) and localized liver cell carcinoma. In early 2016, she was referred to our center with central artery occlusion of the left eye. Tranexamic acid was stopped immediately and anticoagulant therapy was switched to enoxaparin 100mg s.c. qd. However, coagulation parameters deteriorated massively within a few weeks (patelets 36G/l, fibrinogen <0.2g/l, antithrombin 33%, factor XIII 16%, d-dimer 226.5mg/l). In order to control massive bruising and epistaxis, the patient was repeatedly substituted with fibrinogen, concentrate, antithrombin concentrate, and factor XIII concentrate as well as with fresh frozen plasma.

Results: With the idea to control excessive thrombin generation we started a trial with the intravenous direct thrombin inhibitor (DTI) argatroban (subtherapeutic levels). One day after starting this therapy, coagulation parameters improved remarkably with platelets >50G/l, fibrinogen >0.5g/l, factor XIII >30%, antithrombin >30%, d-dimer 50mg/l without the need of further substitution with factor concentrates. In order to discharge the patient in an outpatient setting we decided to continue thrombin inhibition with the oral DTI dabigatran etexilate. Weighing riskf for bleeding and for thromboembolic events, a reduced dose of 75mg bid was used. Thereafter, coagulation parameters remained stable and neither new bleeding events nor thromboembolic events occurred.

Conclusion: Dabigatran etexilate in reduced dose might be an attractive compound to control chronic DIC given its higher potential to inhibit thrombin generation than heparins.