An 85-year old patient with severe ongoing bleeding

In this case report, we describe an 85-year-old female patient who presented with a rare but important problem of anticoagulant rebound complicating dabigatran use. Despite multiple attempts to correct the bleeding, it continued and the coagulation times remained prolonged. Important risk factors for high dabigatran concentrations and prolonged coagulation are renal insufficiency, drug-drug interactions and older age. Treatment of dabigatran-related bleeding with idarucizumab may be complicated by a rebound effect presenting as the reappearance of dabigatran after an initial response. The risk of anticoagulation rebound is higher with higher initial dabigatran levels and is associated with the severity of renal insufficiency. The rebound is best monitored by the diluted thrombin time and may be treated with repeated doses of idarucizumab. In case of persisting bleeding and high dabigatran levels, renal replacement therapy is an acceptable therapeutic option.