Dabigatran (Pradaxa), an antithrombin medication, was discussed in an earlier pearl and thought I would play devil's advocate and explain the possible concerns:

• Yes you don't need INRs to evaluate therapeutic levels but the problem is also don't know if its subtherapeutic or supratherapeutic. This can be an issue during times of transition fromLWMH or coumadin. There are specific protocols to follow for "bridging".
• Though not clinically significant, there was an increase in myocardial infarction in thedabigatran (Pradaxa) group when compared to coumadin - remember vioxx?
• FDA approved dabigatran for stroke prevention, embolism, in AF patients. Though people will automatically translate all of the indications coumadin has that cannot be done yet.
• No reversal agent so in an acute (ED) setting, you are in trouble and are depending on the relatively short half-life to get you out of trouble.

Toxicology Mantra: You never want to be the first person or the last person to use a drug