Dabigatran for stroke prevention in atrial fibrillation: from RE-LY to daily clinical practice

Objective - The RE-LY trial has shown that the oral direct thrombin inhibitor dabigatran etexilate is a valid replacement for oral anticoagulation with vitamin K antagonists (VKA) in patients with atrial fibrillation at thromboembolic risk. After a decade of failures, these results signify a break-through in anticoagulation management. This article summarizes the available evidence from the perspective of the practicing clinician: do the results apply to all patients with AF? And what considerations should we make when prescribing this new oral anticoagulant? Methods and results - We review the trials searching for oral alternatives to VKA therapy, with emphasis on the RE-LY data. We have integrated available interaction data, and data on how to deal with side effects and (bleeding) complications with the direct thrombin inhibitor dabigatran etexilate. Conclusions - Dabigatran etexilate is a viable alternative to VKA, improving efficacy and safety in many respects, for many patients, and likely preferred by most patients themselves. Choosing the dose should be based on patient-specific factors. These include the presence of coronary artery disease (with potential requirement of concomitant aspirin +/- clopidogrel), decreased renal function, age, low body weight, administration of other AF drugs or P-glycoprotein inhibitors, a history of gastro-intestinal bleeding, and patient compliance.