Jacobs Journal of Clinical Case Reports

Profound Coagulopathy, Lactic Acidosis and Acute Renal Failure in a Diabetic patient taking Dabigatran and Metformin

*Vincent J
Department Of Case Reports, The University Of Montana, United States

*Corresponding Author:
Vincent J
Department Of Case Reports, The University Of Montana, United States
Email:vincent.colucci@umontana.edu

Published on: 2017-08-28

Abstract

A 71-year-old female was admitted for treatment of a left hemispheric stroke secondary to uncontrolled hypertension and carotid artery stenosis. Despite worsening renal function, she initiated on dabigatran 150 mg twice daily. Upon discharge, her home medications, including aspirin and metformin, were restarted. Two weeks after discharge she presented to the Emergency Department lethargic and in moderate respiratory distress. An extensive workup revealed lactic acidosis, acute kidney failure, and profound coagulopathy. Transfer to a tertiary care hospital resulted in a nephrology consult and continuous renal replacement therapy (CRRT) to remove accumulated metformin and dabigatran. After 72 hours of supportive treatment, CRRT was discontinued and the profound coagulopathy and lactic acidosis resolved. The absence of dabigatran renal dosage adjustment combined with the metformin-associated lactic acidosis likely contributed to a life-threatening adverse event. This event potentially could have been avoided had the risk factors been identified and appropriate drug adjustments been made prior to her initial discharge.

Keywords

Dabigatran Adverse Event; Acute Renal Failure; Metformin; Profound Coagulopathy; Lactic Acidosis

Introduction

Dabigatran (Pradaxa®) is a direct thrombin inhibitor anticoagulant indicated for treatment and prevention in patients with pulmonary emboli, deep vein thrombosis, and for risk reduction of stroke and systemic emboli associated with non-valvular atrial fibrillation [1]. Until recently, dabigatran did not have a reversal agent, rendering patients taking dabigatran at an increased risk of major bleeding consequences. There is no commercially available biologic surrogate marker to monitor for efficacy and safety or to optimize dabigatran dosing in specific patient populations (e.g, renal insufficiency, obese patients, etc). Dabigatran is eliminated primarily in the urine (80% of total clearance), thus dosing adjustments are warranted for patients with renal insufficiency [1]. Lactic acidosis is a serious, life-threatening but rare adverse reaction that can occur with metformin accumulation [2]. Patients with decreased renal clearance, hepatic disease, and other conditions consistent with hypoperfusion or hypoxemia are at a higher risk for metformin accumulation and possible development of metabolic acidosis [2].