Consumer medicine information

Pradaxa

Dabigatran etexilate

BRAND INFORMATION

Brand name

Pradaxa

Active ingredient

Dabigatran etexilate

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Pradaxa.

What is in this leaflet

This leaflet answers some common questions about Pradaxa.

It does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you taking this medicine against the expected benefits.

If you have any concerns about using this medicine, ask your doctor or pharmacist.

This leaflet was last updated on the date at the end of this leaflet. More recent information may be available. The latest Consumer Medicine Information is available from your pharmacist, doctor or from www.medicines.org.au and may contain important information about the medicine and its use of which you should be aware.

Keep this information with the medicine. You may need to read it again.

What Pradaxa is used for

Pradaxa contains the active substance dabigatran etexilate (as dabigatran etexilate mesilate). After oral use, dabigatran etexilate is rapidly converted in the body to its active form dabigatran. It belongs to a group of medicines called anticoagulants. Some people refer to anticoagulant medicines as "blood thinners". Dabigatran works by inhibiting a specific protein in the blood, called thrombin. Thrombin contributes to the formation of blood clots. Dabigatran prevents the formation of blood clots.

Pradaxa has been prescribed to you for one of the following uses:

  • to prevent the formation of blood clots in the veins after knee or hip replacement surgery in adults
  • to reduce the risk of brain (stroke) and/or other body vessel obstruction by blood clot formation in adults with an abnormal heart beat rhythm called non-valvular atrial fibrillation
  • to treat blood clots in the veins of your legs and lungs and to prevent blood clots from re-occurring in the veins of your legs and/or lungs.

Ask your doctor if you have any questions about why this medicine has been prescribed for you. Your doctor may have prescribed it for another reason.

Before you take Pradaxa

When you must not take it

Do not take Pradaxa if you are allergic to:

  • dabigatran etexilate or any of the other ingredients in Pradaxa listed at the end of this leaflet.

Some of the symptoms of an allergic reaction may include:

  • rash, itching or hives on the skin
  • swelling of the face, lips, tongue or other parts of the body
  • shortness of breath, wheezing or troubled breathing.

Do not take Pradaxa:

  • if you are currently bleeding
  • if you have severely reduced kidney function (your doctor will know how to determine your kidney function)
  • if you have an increased tendency of bleeding complications (this may be inherited, of unknown cause or due to other medicines)
  • if you have a medical condition which increases your risk of serious bleeding, such as recent brain or spinal injury, and cancer
  • if you have active stomach ulcers or have experienced stomach bleeding in the past year, unless the cause has been permanently eliminated, e.g. by surgery
  • if you have a history of bleeding in the head, eyes, spine, abdomen and joints
  • if you have an indwelling spinal or epidural catheter, and during the first two hours after their removal (your doctor will know about the kind of catheters and precautionary measures)
  • if you have liver problems or liver disease
  • if you are currently taking oral ketoconazole or itraconazole, medicines used to treat fungal infections
  • if you are taking dronedarone, a medicine used to treat abnormal heart beat
  • if you are taking ciclosporin or tacrolimus, medicines used to prevent organ rejection after transplantation
  • if you are taking glecaprevir/pibrentasvir, a combination medicine used to treat hepatitis C infection
  • if you are taking medicines to prevent blood clotting (e.g. warfarin, rivaroxaban, apixaban or heparin), except when changing anticoagulant treatment, while having a venous or arterial line and you get heparin through this line to keep it open or while your heart beat is being restored to normal by a procedure called catheter ablation for atrial fibrillation
  • if you have a prosthetic heart valve.

Do not start Pradaxa and verapamil treatment at the same time.

Do not start verapamil if you are currently taking Pradaxa and have just undergone major orthopaedic surgery.

Do not take this medicine if you are pregnant. It may affect your developing baby if you take it during pregnancy.

Do not breastfeed if you are taking this medicine. The active ingredient in Pradaxa passes into breast milk.

Do not give this medicine to a child or adolescent. There is no experience with its use in children or adolescents under 18 years old.

Do not take this medicine after the expiry date printed on the box or if the packaging is torn or shows signs of tampering. If it has expired or is damaged, return it to your pharmacist for disposal. If you use this medicine after the expiry date has passed, it may not work as well.

If you are not sure whether you should start taking this medicine, talk to your doctor.

Before you start to take it

Tell your doctor if you have any allergies to any other medicines or any other substances, such as foods, preservatives or dyes.

Tell your doctor if you are pregnant or intend to become pregnant. Pradaxa should not be used during pregnancy.

Tell your doctor if you are breastfeeding or intend to breastfeed. Pradaxa is not recommended in women who are breastfeeding.

Tell your doctor if you have had a heart attack or if you have been diagnosed with conditions that increase the risk to develop a heart attack.

Tell your doctor if you have reduced liver function, life-threatening liver disease or increased liver enzymes.

Tell your doctor if you have an increased bleeding risk, as could be the case in the following situations:

  • if you are older than 75 years, your doctor may prescribe a lower dose of Pradaxa
  • if you know you have reduced kidney function, or you are suffering from dehydration (symptoms include feeling thirsty and passing reduced amounts of dark-coloured urine)
  • if you have been recently bleeding
  • if you have any problems with your blood
  • if you have had a recent tissue sampling (biopsy)
  • if you have cancer
  • if you have had a serious injury (e.g. a bone fracture, head injury or any injury requiring treatment)
  • if you are suffering from an inflammation of the food pipe (oesophagus) or stomach
  • if you have problems with reflux of gastric juice into the food pipe (oesophagus)
  • if you are receiving medicines which could increase the risk of bleeding, such as clopidogrel and warfarin
  • if you are taking anti-inflammatory medicines such as diclofenac
  • if you are suffering from an infection of the heart (bacterial endocarditis).

Tell your doctor if you know that you have a disease called antiphospholipid syndrome (a disorder of the immune system that causes an increased risk of blood clots).

If you have not told your doctor about any of the above, tell them before you use Pradaxa.

Taking other medicines

Tell your doctor or pharmacist if you are taking any other medicines, including any that you get without a prescription from your pharmacy, supermarket or health food shop.

Some medicines and Pradaxa may interfere with each other. These include:

  • aspirin, salicylates or other NSAID (anti-inflammatory) medicines
  • medicines used to thin your blood (such as warfarin, unfractionated heparins, heparin derivatives (fondaparinux and desirudin), low molecular weight heparins (enoxaparin), clopidogrel, tirofiban, bivalirudin, prasugrel, ticagrelor, eptifibatide, ticlopidine, dextran, sulfinpyrazone, rivaroxaban and apixaban)
  • amiodarone, dronedarone, medicines used to treat irregular heartbeats
  • verapamil, a calcium channel blocker used to treat high blood pressure and angina
  • quinidine, a medicine used to treat malaria and irregular heartbeats
  • clarithromycin or rifampicin, medicines used to treat infections
  • lopinavir, nelfinavir, ritonavir, tipranavir or saquinavir, medicines used to treat HIV infections
  • ciclosporin or tacrolimus, medicines used to help the body's immune system
  • glecaprevir/pibrentasvir, a combination medicine used to treat hepatitis C infection
  • selective serotonin re-uptake inhibitors (SSRI) (e.g. citalopram, escitalopram, fluoxetine), selective serotonin norepinephrine re-uptake inhibitors (SNRI) (e.g. duloxetine, venlafaxine, desvenlafaxine), medicines used to treat mood disorders
  • herbal medicines derived from St John's wort (Hypericum perforatum)
  • carbamazepine, a medicine used to treat fits or convulsions
  • medicines used to treat reflux and stomach ulcers (such as pantoprazole and ranitidine).

These medicines may be affected by Pradaxa or may affect how well it works. You may need different amounts of your medicines, change the timing of your medicine-taking routine or take different medicines. Your doctor or pharmacist will advise you.

Your doctor and pharmacist have more information on medicines to be careful with or avoid while taking Pradaxa.

How to take Pradaxa

Follow the instructions given to you by your doctor or pharmacist carefully. They may differ from the information contained in this leaflet.

If you do not understand the instructions on the box, ask your doctor or pharmacist for help.

How much to take

AFTER KNEE AND HIP REPLACEMENT SURGERY
The recommended dose of Pradaxa is 220 mg (2 capsules of 110 mg) taken as a single dose once daily.

Patients with moderately reduced kidney function (e.g. over 75 years) or patients taking certain medicines may have an increased risk of bleeding. The doctor may prescribe the lower dose of 150 mg once daily, taken as 2 capsules of Pradaxa 75 mg.

Treatment with Pradaxa should be started within 1 - 4 hours of completed surgery, using a single capsule of 110 mg and continuing with 2 capsules of 110 mg once daily for a total of 10 days (after knee replacement surgery) or for a total of 28 - 35 days (after hip replacement surgery).

If, within 4 hours after surgery, post-operative bleedings can still be observed, initiation of treatment should be delayed. If treatment is not started on the day of surgery then treatment should be initiated with 2 capsules of 110 mg once daily.

Follow the initiation instructions given to you by your doctor carefully.

FOR STROKE PREVENTION IN PATIENTS WITH ATRIAL FIBRILLATION
The recommended dose of Pradaxa is 300 mg taken as 1 capsule of 150 mg in the morning and 1 capsule of 150 mg in the evening.

Patients over 75 years should take a lower dose of 220 mg, taken as 1 capsule of 110 mg in the morning and 1 capsule of 110 mg in the evening.

Patients with an increased risk of major bleeding (as determined by your doctor) should take a lower dose of 220 mg, taken as 1 capsule of 110 mg in the morning and 1 capsule of 110 mg in the evening.

FOR THE TREATMENT OF BLOOD CLOTS AND PREVENTION OF BLOOD CLOTS RE-OCCURRING IN THE VEINS OF YOUR LEGS AND/OR LUNGS
The recommended dose of Pradaxa is 300 mg taken as 1 capsule of 150 mg twice a day following treatment with an injectable blood thinner for at least 5 days. To prevent blood clots re-occurring, continue on 1 capsule of 150 mg twice a day.

Patients over 75 years should take a lower dose of 220 mg, taken as 1 capsule of 110 mg in the morning and 1 capsule of 110 mg in the evening. To prevent blood clots re-occurring, continue on 1 capsule of 110 mg twice a day.

Patients with an increased risk of major bleeding (as determined by your doctor) should take a lower dose of 220 mg, taken as 1 capsule of 110 mg in the morning and 1 capsule of 110 mg in the evening. To prevent blood clots re-occurring, continue on 1 capsule of 110 mg twice a day.

Your doctor will decide how long you need to be on this treatment for.

How to take it

Pradaxa is available in blister packs.

REMOVING PRADAXA CAPSULES FROM THE BLISTER PACK

Prior to removing a capsule from the blister card, separate one blister segment by tearing along the perforations (Figure A).

Once you have separated an individual blister segment, locate the tab marked with the arrow (Figure B).

Immediately before you are ready to take your dose of Pradaxa, peel back the foil using the tab marked with the arrow until the capsule is fully visible (Figure C).

Turn the blister segment upside down and tip the capsule out, tapping the back of the blister segment, if necessary.

Do not try to push the capsule through an unopened blister segment.

Do not cut the foil or use sharp instruments to remove the capsule from the blister.

Capsules should always be stored in the sealed blister segments and only removed immediately before use. The capsule should be taken immediately after the foil over an individual blister segment is opened, or its effectiveness may be reduced.

If additional capsules are inadvertently exposed to air, they should not be used and should be discarded.

Capsules should not be removed from the blister pack and repackaged in dose administration aids such as dosette boxes, tablet organisers or weekly medication packs.

Swallow the capsules whole with a full glass of water.

DO NOT CHEW OR OPEN THE CAPSULE. DO NOT SPRINKLE THE PELLETS ON FOOD OR MIX WITH LIQUIDS. This may cause an overdose of Pradaxa and increase the risk of bleeding.

When to take it

Take Pradaxa at about the same time each day. Taking your capsules at the same time each day will have the best effect. It will also help you remember when to take it. It does not matter if you take this medicine with or without food.

How long to take it

Continue taking your medicine for as long as your doctor tells you.

Pradaxa will continue to be prescribed while there is a risk of excessive clotting.

AFTER KNEE REPLACEMENT SURGERY:
This will usually be for a period of 10 days.

AFTER HIP REPLACEMENT SURGERY:
This will usually be for a period of 28 - 35 days.

It is important to keep taking your medicine even if you feel well. If you stop using Pradaxa before your doctor tells you to stop, you are at risk of developing a blood clot in a vein of your leg which can move to the lungs and be life-threatening.

Tell your doctor immediately or go to Emergency at your nearest hospital if you notice swelling of the leg or cough and shortness of breath. These could be signs of a blood clot.

Tell your doctor if you intend stopping treatment earlier.

FOR STROKE PREVENTION IN PATIENTS WITH ATRIAL FIBRILLATION:

It is important to keep taking your medicine even if you feel well. If you stop using Pradaxa before your doctor tells you to stop, you are at risk of developing a blood clot. This can lead to serious health problems such as strokes.

FOR TREATMENT AND PREVENTION OF BLOOD CLOTS RE-OCCURRING IN THE VEINS OF YOUR LEGS AND LUNGS:

It is important to keep taking your medicine even if you feel well. If you stop using Pradaxa before your doctor tells you to stop, you are at risk of developing a blood clot. This can lead to serious health problems if those clots stop blood flowing normally.

If you forget to take it

After knee and hip replacement surgery continue with your remaining daily doses of Pradaxa at the same time of the next day.

Do not take a double dose to make up for missed individual doses.

For stroke prevention in patients with atrial fibrillation a forgotten dose of Pradaxa can still be taken up to 6 hours prior to the next dose.

A missed dose should be omitted if the remaining time is less than 6 hours prior to the next dose.

Do not take a double dose to make up for missed individual doses.

For the treatment and prevention of blood clots re-occurring in the veins of your legs and lungs a forgotten dose of Pradaxa can still be taken up to 6 hours prior to the next dose.

A missed dose should be omitted if the remaining time is less than 6 hours prior to the next dose. Do not take a double dose to make up for missed individual doses.

If you are not sure what to do, ask your doctor or pharmacist.

If you have trouble remembering when to take your medicine, ask your pharmacist for hints.

If you take too much (Overdose)

Immediately telephone your doctor or Poisons Information Centre (Australia 13 11 26) for advice, or go to Emergency at your nearest hospital if you think that you or anyone else may have taken too much Pradaxa.

Do this even if there are no signs of discomfort or poisoning.

If you take too much Pradaxa you may have bleeding. Blood may be seen in stools or urine. Abnormal bruising may also be experienced.

While you are taking Pradaxa

Things you must do

Tell all doctors and pharmacists who are treating you that you are taking Pradaxa.

Tell your doctor if, for any reason, you have not used Pradaxa exactly as prescribed. Otherwise, your doctor may think that it was not effective and change your treatment unnecessarily.

If you become pregnant while using Pradaxa, tell your doctor immediately.

If you are going to have surgery, including dental surgery, tell your doctor or dentist that you are taking Pradaxa.

Your doctor may decide to temporarily stop your treatment with Pradaxa.

Tell your doctor if you fall or injure yourself during treatment, especially if you hit your head, please seek urgent medical attention. You may need to be checked by a doctor, as you may be at increased risk of bleeding.

Things you must not do

Do not give Pradaxa to anyone else, even if they have the same condition as you.

Do not stop taking your medicine or lower the dosage without checking with your doctor.

Things to be careful of

No studies on the effects of Pradaxa on the ability to drive and operate machinery have been performed.

Driving or operating machinery should be avoided for a period of time after orthopaedic surgery.

Side effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking Pradaxa.

All medicines can have side effects. Sometimes they are serious, most of the time they are not.

Do not be alarmed by the following lists of side effects. You may not experience any of them.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor if you notice any of the following and they worry you:

  • bruising
  • nose bleeds
  • stomach ache
  • itchy skin, rash
  • diarrhoea
  • indigestion
  • feeling sick
  • cough
  • painful, swollen joints
  • sore nasal passages and throat
  • discomfort when swallowing
  • hair loss
  • frequent infections such as fever, severe chills, sore throat or mouth ulcers (signs of lack of white blood cells).

These side effects are usually mild.

Tell your doctor immediately or go to Emergency at your nearest hospital if you notice any of the following:

  • long or excessive bleeding
  • exceptional weakness
  • tiredness, headaches, dizziness and looking pale (signs of anaemia)
  • chest pain or being short of breath
  • swelling of hands, ankles and feet
  • red or dark brown urine
  • red or black bowel motions.

These are serious side effects. You may need urgent medical attention.

Other side effects not listed above may occur in some people.

Tell your doctor if you notice anything else that is making you feel unwell.

After using Pradaxa

Storage

Keep your capsules in the blister pack until it is time to take them. If you take them out of the blister pack they may not keep well.

Keep Pradaxa in a cool dry place where the temperature stays below 30°C.

Do not store Pradaxa or any other medicine in the bathroom or near a sink.

Do not leave it in the car or on window sills. Heat and dampness can destroy some medicines.

Keep Pradaxa where children cannot reach it. A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Disposal

If your doctor tells you to stop taking Pradaxa or it has passed its expiry date, ask your pharmacist what to do with any that is left over.

Product Description

What it looks like

Pradaxa is the brand name of your medicine.

Pradaxa is available in three strengths of capsules:

  • Pradaxa 75 mg - white-coloured, opaque cap and body, imprinted with a R75 code on one side and company logo on the other
  • Pradaxa 110 mg - light blue-coloured, opaque cap and body, imprinted with a R110 code on one side and company logo on the other
  • Pradaxa 150 mg - light blue-coloured, opaque cap with a white-coloured, opaque body imprinted with a R150 code on one side and company logo on the other.

Pradaxa 75 mg, 110 mg and 150 mg are available in blister packs of 10 and 60 capsules. Pradaxa 75 mg and 110 mg are also available in blister packs of 30* capsules.

* Not distributed in Australia.

Ingredients

Active ingredient:

  • Pradaxa 75 mg - 75 mg dabigatran etexilate given as 86.48 mg dabigatran etexilate mesilate per capsule.
  • Pradaxa 110 mg - 110 mg dabigatran etexilate given as 126.83 mg dabigatran etexilate mesilate per capsule.
  • Pradaxa 150 mg - 150 mg dabigatran etexilate given as 172.95 mg dabigatran etexilate mesilate per capsule.

Inactive ingredients:

Capsule fill

  • acacia
  • dimeticone 350
  • hyprolose
  • hypromellose
  • purified talc
  • tartaric acid

Capsule shell

  • carrageenan
  • potassium chloride
  • titanium dioxide
  • indigo carmine CI73015 (110 mg and 150 mg capsules only)
  • hypromellose
  • purified water

Black printing ink

  • TekPrint SW-9008 Black Ink.

Pradaxa does not contain gluten, sucrose or tartrazine.

Supplier

Pradaxa is supplied in Australia by:

Boehringer Ingelheim Pty Limited
ABN 52 000 452 308
Sydney, Australia
www.boehringer-ingelheim.com.au

This Consumer Medicine Information was updated in February 2020.

® Pradaxa is a registered trademark of Boehringer Ingelheim.

© Boehringer Ingelheim Pty Limited 2020

Australian Registration Numbers

Pradaxa 75 mg: AUST R 137832

Pradaxa 110 mg: AUST R 138402

Pradaxa 150 mg: AUST R 168211

Published by MIMS April 2020

BRAND INFORMATION

Brand name

Pradaxa

Active ingredient

Dabigatran etexilate

Schedule

S4

 

1 Name of Medicine

Dabigatran etexilate (as dabigatran etexilate mesilate).

6.7 Physicochemical Properties

Dabigatran etexilate mesilate is a yellow-white to yellow crystalline powder; the crystals have a rod-like habit. It contains two weak basic centers with pKa values of 4.0 ± 0.1 (benzimidazol moiety) and 6.7 ± 0.1 (carbamic acid hexyl ester moiety). Its solubility in water is strongly pH dependent with rather high solubility in acidic media (> 50 mg/mL in 0.1 N HCl) and very poor solubility in neutral and basic media (0.003 mg/mL at pH 7.4). The solubility in water is 1.8 mg/mL (0.18%). In its neutral form it is very lipophilic (log P = 3.8, determined in different mixtures of aqueous solution and n-octanol).
Dabigatran etexilate mesilate is Ethyl N-{[2-({[4-((E)- amino{[hexyloxy) carbonyl]imino} methyl)phenyl] amino}methyl)- 1-methyl-1H- benzimidazol- 5-yl]carbonyl}- N-pyridin-2-yl- β-alaninate methanesulfonate.
Molecular Formula: C35H45N7O8S.
Molecular Weight: 627.75 (free base); 723.86 (mesilate salt).

Chemical structure.


CAS number.

CAS Registry Number: 211915-06-9 (free base);
593282-20-3 (mesilate).

2 Qualitative and Quantitative Composition

Pradaxa are hard capsules for oral administration.
Pradaxa 75 mg hard capsules contain 75 mg dabigatran etexilate.
Pradaxa 110 mg hard capsules contain 110 mg dabigatran etexilate.
Pradaxa 150 mg hard capsules contain 150 mg dabigatran etexilate.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Capsules 75 mg: Imprinted hypromellose capsules with white opaque cap and body of size 2 filled with yellowish pellets. The cap is imprinted with the Boehringer Ingelheim company symbol, the body with R75.
Capsules 110 mg: Imprinted hypromellose capsules with light blue opaque cap and body of size 1 filled with yellowish pellets. The cap is imprinted with the Boehringer Ingelheim company symbol, the body with R110.
Capsules 150 mg: Imprinted hypromellose capsules with light blue opaque cap and white opaque body of size 0 filled with yellowish pellets. The cap is imprinted with the Boehringer Ingelheim company symbol, the body with R150.

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Dabigatran etexilate is a small molecule prodrug which does not exhibit any pharmacological activity. After oral administration, dabigatran etexilate is rapidly absorbed and converted to dabigatran by esterase-catalysed hydrolysis in plasma and in the liver. Dabigatran is a competitive (Ki = 4.5 nanoM) and reversible direct thrombin inhibitor and is the main metabolite of dabigatran etexilate in plasma.
Since thrombin (serine protease) enables the conversion of fibrinogen into fibrin during the coagulation cascade, its inhibition prevents the development of thrombus. Dabigatran also inhibits free thrombin, fibrin-bound thrombin and thrombin-induced platelet aggregation.
In vivo and ex vivo animal studies have demonstrated antithrombotic efficacy and anticoagulant activity of dabigatran after intravenous administration and of dabigatran etexilate after oral administration in various animal models of venous thrombosis.
There is a close correlation between plasma dabigatran concentration and degree of anticoagulant effect. Prothrombin time (PT, expressed as international normalised ratio (INR)) is too insensitive to reliably detect anticoagulant activity of dabigatran and is therefore not recommended as a suitable tool for monitoring anticoagulant activity. Ecarin clotting time (ECT), thrombin time (TT) and diluted thrombin time (dTT) are sensitive assays that increase in direct proportion to dabigatran plasma concentration without any deviation from linearity at high plasma concentrations. However, ECT is not readily available in clinical practice. Activated partial thromboplastin time (aPTT) increases in a non-linear manner to dabigatran concentration and is less proportional at higher dabigatran concentrations (see Section 4.4 Special Warnings and Precautions for Use, Effect on laboratory tests). ECT, TT and aPTT are not standardised or validated with dabigatran for commercial use. In cases of emergency, TT and aPTT are the most accessible qualitative methods for determining the presence or absence of the anticoagulant effect of dabigatran.
Interpretation of coagulation assay results should consider time of dabigatran etexilate administration relative to time of blood sampling (see Section 5.2 Pharmacokinetic Properties, Absorption).
In patients undergoing elective hip replacement surgery, greater test variability with aPTT and ECT was observed. The mechanisms for this variability immediately after surgery are unclear and aPTT and ECT levels measured in the first 2-3 days following surgery should be interpreted with caution.
Whilst Pradaxa does not require routine laboratory anticoagulant monitoring, careful clinical monitoring including renal function testing is required for all patients (see Section 4.2 Dose and Method of Administration, Special patient populations; Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk).

Clinical trials.

Prevention of venous thromboembolic events (VTE) in adult patients who have undergone major orthopaedic surgery (pVTEp orthopaedic surgery).

In 2 large randomised, parallel group, double-blind, dose-confirmatory trials, patients undergoing elective major orthopaedic surgery (one for knee replacement surgery and one for hip replacement surgery) received dabigatran etexilate 75 mg or 110 mg within 1-4 hours of surgery followed by 150 or 220 mg once daily thereafter, haemostasis having been secured, or enoxaparin 40 mg on the day prior to surgery and once daily thereafter.
Both trials were performed in centres of countries located on 3 continents (Africa, Australia and Europe).
In the RE-MODEL trial (knee replacement) treatment was for 6-10 days and in the RE-NOVATE trial (hip replacement) for 28-35 days. Totals of 2076 patients (knee) and 3494 (hip) were treated, respectively.
Enrolled patients were scheduled to have total knee or hip replacement surgery; 18 years of age or older and weighing at least 40 kg. Patients were excluded if there was a history of bleeding diathesis; coagulation disorders; major surgery or trauma (e.g. hip fracture) within the last 3 months; recent unstable cardiovascular disease or history of myocardial infarction within the last 3 months; greater than 3 attempts or traumatic placement for spinal or epidural anaesthesia; history of haemorrhagic stroke or intracranial pathology such as bleeding, neoplasm, AV malformation or aneurysm; history of VTE or pre-existing condition requiring anticoagulant therapy; clinically relevant bleeding within the last 6 months; gastric or duodenal ulcer within the last 6 months; liver disease which was expected to have a potential impact on survival; elevated AST or ALT > 2 x ULN; severe renal insufficiency (CrCl < 30 mL/min); elevated creatinine which contraindicated venography; treatment within 7 days with anticoagulants: clopidogrel, ticlopidine, abciximab, aspirin > 160 mg/day or NSAID with t1/2 > 12 hours or requiring these medicines during the study treatment period; intermittent pneumatic compression and electric stimulation of lower limb; pregnant or nursing women and pre-menopausal women without acceptable birth control; allergy to radio-opaque contrast media or iodine; thrombocytopenia or platelet count < 100,000 cells/microL; allergy to heparins or dabigatran and dabigatran etexilate; active malignant disease or currently receiving cytostatic treatment; participated in a clinical trial in the last 30 days; leg amputee; alcohol or drug abuse and contraindications to enoxaparin.
For the knee study (RE-MODEL), the median age was 68 years for all treatment groups. The majority of patients were female in all treatment groups (64.2-68.9%). The mean BMI was also similar in all 3 treatment groups with 29.9 (dabigatran etexilate 220 mg), 30.1 (dabigatran etexilate 150 mg), and 29.8 kg/m2 (enoxaparin), respectively.
For the hip study (RE-NOVATE), the median age was 65 years for all treatment groups. The majority of patients were female in all treatment groups (55.5-57.4%) and almost all patients were of white ethnic origin. The median BMI was 27.3 kg/m2 in both dabigatran etexilate groups and 27.1 kg/m2 in the enoxaparin group.
The most widely used type of anaesthesia was spinal anaesthesia. The second most frequent type of anaesthesia was general anaesthesia.
Both the knee (RE-MODEL) and the hip (RE-NOVATE) studies were non-inferiority studies. For determination of the minimal important difference against enoxaparin, the placebo controlled studies with enoxaparin 40 mg QD were pooled and the incidences of deep vein thrombosis (DVT), total VTE and all cause mortality for enoxaparin against placebo for each indication analysed. For the knee study (RE-MODEL), one-third of the lower boundary of the 95% CI, i.e. 9.2%, was chosen to represent a rather strict and conservative estimate of the non-inferiority margin. For the hip study (RE-NOVATE), one-third of the lower boundary of the 95% CI, 7.7% was chosen as the non-inferiority margin.
The results of the knee study (RE-MODEL) with respect to the primary end-point, total venous thromboembolism (VTE) including asymptomatic VTE plus all-cause mortality showed that the antithrombotic effect of both doses of dabigatran etexilate were statistically non-inferior to that of enoxaparin.
Similarly, total VTE including asymptomatic VTE and all-cause mortality constituted the primary end-point for the hip study (RE-NOVATE). Again dabigatran etexilate at both once daily doses was statistically non-inferior to enoxaparin 40 mg daily.
Data for the major VTE and VTE-related mortality end-point and adjudicated major bleeding endpoints are shown in Table 21. VTE was defined as the composite incidence of deep vein thrombosis and pulmonary embolism.
A third trial involving patients undergoing total knee replacement surgery received dabigatran etexilate 75 mg or 110 mg within 6-12 hours of surgery followed by 150 mg and 220 mg once daily thereafter for 12-15 days (RE-MOBILIZE). The comparator dosage of enoxaparin was 30 mg twice daily according to the US label. In the RE-MOBILIZE trial, non-inferiority was not established. There were no statistical differences in bleeding between the comparators.
A fourth trial involving patients undergoing hip replacement surgery received dabigatran etexilate 110 mg on the day of surgery followed by 220 mg once daily thereafter, or enoxaparin 40 mg on the day prior to surgery and daily thereafter (RE-NOVATE II). The duration of treatment was 28-35 days. In the RE-NOVATE II trial, dabigatran etexilate was statistically non-inferior to enoxaparin 40 mg daily for total VTE events and all-cause mortality.
In addition, a randomised, parallel group, double-blind, placebo-controlled phase II study, in Japanese patients where dabigatran etexilate 110 mg, 150 mg and 220 mg was administered once daily beginning the next day after elective total knee replacement surgery, was evaluated. The Japanese study showed an inverse relationship between dabigatran etexilate dose and the incidence of the primary endpoint (total VTE and all-cause mortality). The highest dabigatran etexilate dose resulted in the lowest incidence of total VTE and all-cause mortality.
In RE-MODEL and RE-NOVATE and RE-NOVATE II the randomisation to the respective study medication was done pre-surgery, and in the RE-MOBILIZE and Japanese placebo-controlled trial the randomisation to the respective study medication was done post-surgery. This is of note especially in the safety evaluation of these trials. In Table 21, three of the trials have been grouped in to pre- and post-surgery randomised trials.
Table 22 presents the combined incidences of major VTE and VTE related mortality for RE-MODEL and RE-NOVATE trials. The most frequent component of the composite endpoint was proximal DVT in all three treatment groups. Non-fatal pulmonary embolism (PE) during the treatment period in the two trials were observed in 1 patient in the dabigatran etexilate 150 mg group, 3 patients receiving enoxaparin and 5 patients receiving dabigatran etexilate 220 mg. VTE related mortality was observed for 1 patient in each of the dabigatran etexilate 220 mg and enoxaparin groups and for 4 patients in the dabigatran etexilate 150 mg group. See Table 23.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (SPAF).

The clinical evidence for the efficacy of dabigatran etexilate is derived from the RE-LY study (Randomised Evaluation of Long-term anticoagulant therapy) a multi-centre, multinational, randomised parallel group study of two blinded doses of dabigatran (110 mg twice daily and 150 mg twice daily) compared to open label warfarin in patients with non-valvular atrial fibrillation (AF) at moderate to high risk of stroke or systemic embolism. This trial used the Prospective Randomised Open label trial with Blinded Evaluation of outcomes (PROBE) design. The primary objective in this study was to determine if dabigatran was non-inferior to warfarin in reducing the occurrence of the composite endpoint, stroke and systemic embolic events (SEE).
In the RE-LY study, a total of 18,113 patients were randomised, with a mean age of 71.5 years and a mean CHADS2 score of 2.1. The population had approximately equal proportions of patients with CHADS2 score 1, 2 and ≥ 3. The patient population was 64% male, 70% Caucasian and 16% Asian. RE-LY had a median treatment of 20 months with dabigatran etexilate given as fixed dose without coagulation monitoring. In addition to documented non-valvular AF e.g. persistent, paroxysmal or permanent AF, patients had one of the following additional risk factors for stroke:
previous stroke, transient ischaemic attack or systemic embolism;
left ventricular ejection fraction ≤ 40%;
symptomatic heart failure, ≥ NYHA class 2;
age ≥ 75 years;
age ≥ 65 years associated with one of the following: diabetes mellitus, coronary artery disease (CAD), or hypertension.
Patients were excluded if they had prosthetic heart valves requiring anticoagulation or with haemodynamically relevant valve disease that was expected to require surgical intervention during the course of the study; severe disabling stroke within the previous 6 months or any stroke within the previous 14 days; conditions associated with an increased risk of bleeding: major surgery in the previous month, planned surgery or intervention in the next 3 months, history of intracranial, intraocular, spinal, retroperitoneal or atraumatic intra-articular bleeding unless the causative factor has been permanently eliminated or repaired (e.g. by surgery); gastrointestinal haemorrhage within the past year unless the cause has been permanently eliminated (e.g. surgery); symptomatic or endoscopically documented gastroduodenal ulcer disease in the previous 30 days; haemorrhagic disorder or bleeding diathesis; need for anticoagulant treatment for disorders other than atrial fibrillation; fibrinolytic agents within 48 hours of study entry; uncontrolled hypertension (SBP > 180 mmHg and/or DBP > 100 mmHg); recent malignancy or radiation therapy (≤ 6 months) and not expected to survive 3 years; contraindication to warfarin treatment; reversible causes of atrial fibrillation (e.g. cardiac surgery, pulmonary embolism, untreated hyperthyroidism); plan to perform a pulmonary vein ablation or surgery for cure of the AF; severe renal impairment (estimated creatinine clearance ≤ 30 mL/min); active infective endocarditis; active liver disease, including but not limited to persistent ALT, AST, alkaline phosphatase ≥ 2 x ULN, known active hepatitis C, active hepatitis B, active hepatitis A; women who were pregnant, lactating or of childbearing potential who refused to use a medically acceptable form of contraception throughout the study; anaemia (haemoglobin < 100 g/L) or thrombocytopenia (platelet count < 100 x 109/L); patients who had developed transaminase elevations upon exposure to ximelagatran; patients who had received an investigational drug in the past 30 days or were participating in another drug study; patients considered unreliable by the investigator concerning the requirements for follow-up during the study and/or compliance with study drug administration.
The concomitant diseases of patients in this trial included hypertension 79%, diabetes 23% and CAD 28%. 50% of the patient population was vitamin K antagonist (VKA) naïve defined as less than 2 months total life time exposure. 32% of the population had never been exposed to a VKA. For those patients randomised to warfarin, the time in therapeutic range (INR 2.0 to 3.0) for the trial was a median of 67%. Concomitant medications included acetylsalicylic acid (ASA) (25% of subjects used at least 50% of the time in study), clopidogrel (3.6%), ASA + clopidogrel (2%), NSAIDs (6.3%), beta-blockers (63.4%), diuretics (53.9%), statins (46.4%), ACE-inhibitors (44.6%), angiotensin receptor blockers (26.1%), oral hypoglycaemics (17.5%), insulin (5.2%), digoxin (29.4%), amiodarone (11.3%), diltiazem (8.9%), verapamil (5.4%) and proton pump inhibitors (17.8%).
For the primary endpoint, stroke and systemic embolism, no subgroups (i.e. age, weight, gender, renal function, ethnicity, etc.) were identified with a different risk ratio compared to warfarin.
Based on the intent to treat population analysis, this study demonstrated that dabigatran etexilate, at a dose of 150 mg twice daily, is superior to warfarin in the prevention of stroke and systemic embolism in patients with atrial fibrillation. The lower dose of 110 mg twice daily is non-inferior to warfarin (see Table 24).
Dabigatran etexilate 150 mg twice daily reduces other clinically relevant endpoints: ischaemic stroke, haemorrhagic stroke, intracranial haemorrhage and total bleeding compared to warfarin, with similar rates of major bleeding (see Tables 10 and 25). Dabigatran etexilate 110 mg twice daily reduces the risk of intracranial haemorrhage, major bleeding and total bleeding (see Table 20). The yearly event rate for vascular death for dabigatran etexilate 150 mg twice daily was 2.28%, 110 mg twice daily was 2.43% and warfarin was 2.69%.
There was an increased frequency in myocardial infarction events in subjects treated with dabigatran etexilate compared to warfarin treated subjects, which was not statistically significant (yearly event rate: 150 mg twice daily 0.81%, 110 mg twice daily 0.83%, warfarin 0.64%). Patients had similar baseline characteristics across the treatment groups, with respect to cardiovascular risk factors: hypertension, diabetes, prior coronary artery disease, prior MI, prior stroke, and active smoking. The baseline use of anti-platelet and antithrombotic therapies was similar across the three treatment groups. The reason for this finding is unknown.
Gastrointestinal (GI) haemorrhage occurred at a higher frequency with dabigatran etexilate compared to warfarin. The underlying mechanism of the increased rate of GI bleeding has not been established. See Figure 1 and Tables 26 and 27.
The RE-LY extension study (RELY-ABLE) provided additional safety information for a large cohort of patients which continued the same dose of dabigatran etexilate as assigned in the RE-LY trial. Patients were eligible for the RELY-ABLE trial if they had not permanently discontinued study medication at the time of their final RE-LY study visit. Enrolled patients continued to receive the same double-blind dabigatran etexilate dose randomly allocated in RE-LY, for up to 43 months of follow-up after RE-LY (total mean follow-up RE-LY + RELY-ABLE, 4.5 years). There were 5897 patients enrolled, representing 49% of patients originally randomly assigned to receive dabigatran etexilate in RE-LY and 86% of RELY-ABLE-eligible patients.
During the additional 2.5 years of treatment in RELY-ABLE, with a maximum exposure of over 6 years (total exposure in RELY + RELY-ABLE), the long-term safety profile of dabigatran etexilate was confirmed for both test doses. No new safety findings were observed.
The rates of outcome events including major bleed and other bleeding events were consistent with those seen in RE-LY.
Further to the RE-LY trial, an international, non-interventional study (GLORIA-AF), prospectively collected (in its second phase) safety and effectiveness data in newly diagnosed non valvular atrial fibrillation patients on dabigatran etexilate in a real-world setting. The study included 4,859 patients on dabigatran etexilate (dosages according to local clinical practice and local label; 55% treated with 150 mg bid, 43% treated with 110 mg bid, 2% treated with 75 mg bid). Patients were followed-up for 2 years. The mean CHADS2 and HAS-BLED scores were 1.9 and 1.2, respectively, compared to a mean CHADS2 and HAS-BLED score of 2.1 and 1.3 in RE-LY, respectively. Mean on-therapy follow-up time was 18.3 months. Major bleeding occurred in 0.97 per 100 patient-years. Life-threatening bleeding was reported in 0.46 per 100 patient-years, intracranial haemorrhage in 0.17 per 100 patient-years and gastrointestinal bleeding in 0.60 per 100 patient-years. Stroke occurred in 0.65 per 100 patient-years.
These observations in real world settings were generally consistent with the safety and efficacy profile for dabigatran etexilate in RE-LY.

Patients who underwent percutaneous coronary intervention (PCI) with stenting.

A prospective, randomised, open-label, blinded endpoint (PROBE) study (Phase IIIb) to evaluate dual-therapy with dabigatran etexilate (110 mg or 150 mg bid) plus clopidogrel or ticagrelor (P2Y12 antagonist) vs. triple-therapy with warfarin (adjusted to a INR 2.0 - 3.0) plus clopidogrel or ticagrelor and aspirin was conducted in 2725 patients with non valvular atrial fibrillation who underwent a PCI with stenting (RE-DUAL PCI). Patients were randomised to dabigatran etexilate 110 mg bid dual-therapy, dabigatran etexilate 150 mg bid dual-therapy or warfarin triple-therapy. Elderly patients outside of the United States (≥ 80 years of age for all countries, ≥ 70 years of age for Japan) were randomly assigned to the dabigatran etexilate 110 mg dual-therapy group or the warfarin triple-therapy group. The primary endpoint was a combined endpoint of major bleeds based on ISTH definition or clinically relevant non-major bleeding event.
The incidence of the primary endpoint was 15.4% (151 patients) in the dabigatran etexilate 110 mg dual-therapy group as compared with 26.9% (264 patients) in the warfarin triple-therapy group (HR 0.52; 95% CI 0.42, 0.63; p < 0.0001 for non-inferiority and p < 0.0001 for superiority) and in 20.2% (154 patients) in the dabigatran etexilate 150 mg dual-therapy group as compared with 25.7% (196 patients) in the corresponding warfarin triple-therapy group (HR 0.72; 95% CI 0.58, 0.88; p < 0.0001 for non-inferiority). Both dabigatran etexilate dual-therapy groups had lower rates of intracranial haemorrhage than the corresponding warfarin triple-therapy group: 3 events (0.3%) in the 110 mg dabigatran etexilate dual-therapy group as compared with 10 events (1.0%) in the warfarin triple-therapy group and 1 event (0.1%) in the 150 mg dabigatran etexilate dual-therapy group as compared with 8 events (1.0%) in the corresponding warfarin triple-therapy group. The incidence of the composite efficacy endpoint of death, thromboembolic events (myocardial infarction, stroke, or systemic embolism) or unplanned revascularisation in the two dabigatran etexilate dual-therapy groups combined was non-inferior to the warfarin triple-therapy group (13.7% vs. 13.4% respectively; HR 1.04; 95% CI: 0.84, 1.29; p=0.0047 for non-inferiority).There were no statistical differences in the individual components of the efficacy endpoints between either dabigatran etexilate dual-therapy groups and warfarin triple-therapy.
This study demonstrated that dual-therapy, with dabigatran etexilate and a P2Y12 antagonist, substantially reduced the risk of bleeding vs. warfarin triple-therapy, with non-inferiority for composite of thromboembolic events, in patients with atrial fibrillation who underwent a PCI with stenting.

Patients undergoing catheter ablation for atrial fibrillation.

A prospective, randomised, open-label, multicentre, exploratory study with blinded, centrally adjudicated endpoint evaluation (RE-CIRCUIT) was conducted in 704 patients who were under stable anticoagulant treatment. The study compared 150 mg twice daily uninterrupted dabigatran etexilate with uninterrupted INR-adjusted warfarin in catheter ablation of paroxysmal or persistent atrial fibrillation. Of the 704 enrolled patients, 317 underwent atrial fibrillation ablation on uninterrupted dabigatran and 318 underwent atrial fibrillation ablation on uninterrupted warfarin. All patients underwent a Trans-oesophageal Echocardiography (TEE) prior to catheter ablation. The primary outcome (adjudicated major bleeding according to ISTH criteria) occurred in 5 (1.6%) patients in the dabigatran etexilate group and 22 (6.9%) patients in the warfarin group (risk difference -5.3%; 95% CI -8.4, -2.2; nominal p = 0.0009). There was no stroke/systemic embolism/TIA (composite) event in the dabigatran etexilate arm, and one event (TIA) in the warfarin arm from the time of ablation and until 8 weeks post-ablation. This exploratory study showed that dabigatran etexilate was associated with a significant reduction in MBE rate compared with INR-adjusted warfarin in the setting of ablation.

Treatment of deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

The efficacy and safety was investigated in two multi-centre, randomised, double blind, parallel-group, replicate studies RE-COVER and RE-COVER II. These studies compared dabigatran etexilate (150 mg twice daily) with warfarin (target INR 2.0-3.0) in patients with acute DVT and/or PE. Patients were to be included in the studies if they had objectively confirmed symptomatic uni- or bi-lateral DVT of the leg and/or confirmed symptomatic PE. Patients were not eligible to participate in any study if they had of any of the following at screening: excessive risk of bleeding, CrCL below 30 mL/min, known liver disease expected to have any potential impact on survival or pregnancy, breast feeding, or not using adequate contraceptive methods. The primary objective of these studies was to determine if dabigatran was non-inferior to warfarin in reducing the occurrence of the primary endpoint which was the composite of recurrent symptomatic DVT and/or PE and related deaths within the 6 month acute treatment period. The lower bound of the non-inferiority margin was 2.75 in hazard ratio.
In the pooled RE-COVER and RE-COVER II studies, a total of 5,153 patients were randomised and 5,107 were treated. The index events at baseline: DVT - 68.5%, PE - 22.2%, PE and DVT - 9.1%. The most frequent risk factors were history of DVT and/or PE - 21.5%, surgery/ trauma - 18.1%, venous insufficiency - 17.6%, and prolonged immobilisation - 14.6%. Patients' baseline characteristics: mean age was 54.8 years, males 59.5%, Caucasian 86.1%, Asian 11.8%, blacks 2.1%. The co-morbidities included: hypertension 35.5%, diabetes mellitus 9.0%, CAD 6.8% and gastric or duodenal ulcer 4.1%.
The duration of treatment with fixed dose of dabigatran was 174.0 days without coagulation monitoring. For patients randomised to warfarin, the median time in therapeutic range (INR 2.0 to 3.0) was 60.6%. Concomitant medications included vasodilators 28.5%, agents acting on the renin angiotensin system 24.7%, lipid lowering agents 19.1%, beta-blockers 14.8%, calcium channel blockers 9.7%, NSAIDs 21.7%, aspirin 9.2%, antiplatelet agents 0.7%, P-gp inhibitors 2.0% (verapamil - 1.2% and amiodarone - 0.4%).
Two trials in patients presenting with acute DVT and/or PE treated initially for at least 5 days of parenteral therapy, RE-COVER and RE-COVER II, demonstrated that treatment with dabigatran etexilate 150 mg twice daily was non-inferior to the treatment with warfarin (p-values for non-inferiority: RE-COVER p < 0.0001, RE-COVER II p = 0.0002). See Section 4.8 Adverse Effects (Undesirable Effects) for information on bleeding events in RE-COVER and RE-COVER II. See Table 28.

Prevention of recurrent deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

Two randomised, parallel group, double-blind studies were performed in patients previously treated with anticoagulation therapy. RE-MEDY, the warfarin controlled study, enrolled patients already treated for 3 to 12 months with the need for further anticoagulant treatment and RE-SONATE, the placebo controlled study, enrolled patients already treated for 6 to 18 months with vitamin K inhibitors. Patients were to be included in the RE-MEDY or RE-SONATE study if they had objectively confirmed DVT or PE and had prior treatment with an oral anticoagulant for between 3 and 18 months (varied by study). The RE-MEDY study was designed to recruit typical patients at risk of recurrent VTE; RE-SONATE was designed to recruit patients at lower risk who might benefit from extended anticoagulation. Patients were not eligible to participate in any study if they had any of the following at screening: excessive risk of bleeding, CrCL below 30 mL/min, known liver disease expected to have any potential impact on survival or pregnancy, breast feeding, or not using adequate contraceptive methods.
The objective of the RE-MEDY study was to compare the safety and efficacy of oral dabigatran etexilate (150 mg twice daily) to warfarin (target INR 2.0-3.0) for the long-term treatment and prevention of recurrent, symptomatic DVT and/or PE. A total of 2,866 patients were randomised and 2,856 patients were treated. The index events at baseline: DVT - 65.1%, PE - 23.1%, PE and DVT - 11.7%. Patients' baseline characteristics: mean age 54.6 years, males 61.0%, Caucasian 90.1%, Asian 7.9%, blacks 2.0%. Co-morbidities included hypertension 38.6%, diabetes mellitus 9.0%, CAD 7.2% and gastric or duodenal ulcer 3.8%. Concomitant medications: agents acting on the renin angiotensin system 27.9%, vasodilators 26.7%, lipid lowering agents 20.6%, NSAIDs 18.3%, beta-blockers 16.3%, calcium channel blockers 11.1%, aspirin 7.7%, P-gp inhibitors 2.7% (verapamil 1.2% and amiodarone 0.7%), antiplatelets 0.9%. Duration of dabigatran exilate treatment ranged from 6 to 36 months (median - 534.0 days). For patients randomised to warfarin, the median time in therapeutic range (INR 2.0-3.0) was 64.9%.
RE-MEDY demonstrated that treatment with dabigatran etexilate 150 mg twice daily was non-inferior to warfarin (p = 0.0135 for non-inferiority). See Section 4.8 Adverse Effects (Undesirable Effects) for information on bleeding events in RE-MEDY.
As in the pooled RE-COVER/RE-COVER II studies, in RE-MEDY concomitant use of P-gp inhibitors was reported by few patients (2.7%); verapamil (1.2%) and amiodarone (0.7%) were the most frequent. In the pooled acute VTE treatment studies, concomitant use of P-gp inhibitors was reported by few patients (2.0%); most frequent were verapamil (1.2% overall) and amiodarone (0.4% overall).
Table 29 displays details of key results of the RE-MEDY study.
The objective of the RE-SONATE study was to evaluate superiority of dabigatran etexilate versus placebo for the prevention of recurrent symptomatic DVT and/or PE in patients who had already completed 6 to 18 months of treatment with VKA. The intended therapy was 6 months dabigatran etexilate 150 mg twice daily without need for monitoring.
The index events at baseline: DVT 64.5%, PE 27.8%, PE and DVT 7.7%. A total of 1,353 patients were randomized and 1,343 patients treated. Patients' baseline characteristics: mean age 55.8 years, males 55.5%, Caucasian 89.0%, Asian 9.3%, blacks 1.7%. Co-morbidities included hypertension 38.8%, diabetes mellitus 8.0%, CAD 6.0% and gastric or duodenal ulcer 4.5%. Concomitant medications: agents acting on the renin-angiotensin system 28.7%, vasodilators 19.4%, lipid lowering agents 17.9%, beta-blockers 18.5%, calcium channel blockers 8.9%, NSAIDs 12.1%, aspirin 8.3%, antiplatelets 0.7% and P-gp inhibitors 1.7% (verapamil 1.0% and amiodarone 0.3%).
RE-SONATE demonstrated dabigatran etexilate was superior to placebo for the prevention of recurrent symptomatic DVT/PE events including unexplained deaths, with a risk reduction of 92% (absolute risk reduction 5.2%) during the treatment period (p < 0.0001). All secondary and sensitivity analyses of the primary endpoint and all secondary endpoints showed superiority of dabigatran etexilate over placebo. The rates of MBEs and the combination of MBEs/CRBEs were significantly higher in patients receiving dabigatran etexilate as compared with those receiving placebo.
The study included observational follow-up for 12 months after the conclusion of treatment. After discontinuation of study medication the effect was maintained until the end of the follow-up, indicating that the initial treatment effect of dabigatran etexilate was sustained. No rebound effect was observed. At the end of the follow-up VTE events in patients treated with dabigatran etexilate was 6.9% vs. 10.7% among the placebo group (hazard ratio 0.61 (0.42, 0.88), p = 0.0082).
Table 30 displays details of key results of the RE-SONATE study.

Other measures evaluated.

Liver function tests.

In the active controlled studies RE-COVER, RE-COVER II and RE-MEDY, potential abnormalities of liver function tests (LFT) occurred with a comparable or lower incidence in dabigatran etexilate vs. warfarin treated patients. In RE-SONATE, there was no marked difference between the dabigatran and placebo groups with regard to possible clinically significant abnormal LFT values.

Prevention of thromboembolism in patients with prosthetic heart valves.

A phase II study examined dabigatran etexilate and warfarin in a total of 252 patients with recent mechanical heart valve replacement surgery (i.e. within the current hospital stay) and in patients who received a mechanical heart valve replacement more than three months before. Analysis of the study data revealed more thromboembolic events, including stroke, transient ischaemic events, valve thrombosis and myocardial infarction in the patients assigned to treatment with dabigatran etexilate compared with warfarin. In the early post-operative patients, major bleeding manifested predominantly as haemorrhagic pericardial effusions, specifically in patients who started dabigatran etexilate early (i.e. on Day 3) after heart valve replacement surgery.

5.2 Pharmacokinetic Properties

Absorption.

After oral administration of dabigatran etexilate in healthy volunteers, the pharmacokinetic profile of dabigatran in plasma is characterised by a rapid increase in plasma concentrations with Cmax attained within 0.5 and 2.0 hours post administration. Cmax and the area under the plasma concentration-time curve were dose proportional. After Cmax, plasma concentrations of dabigatran showed a biexponential decline with a mean terminal half-life of 12-14 hours in elderly healthy volunteers and 14-17 hours in patients undergoing major orthopaedic surgery. The half-life was independent of dose. However, half-life is prolonged if renal function is impaired as shown in Table 31.
Upon administration of the dabigatran etexilate HPMC capsules together with a high fat, high caloric breakfast, the average total exposure (AUC) of dabigatran increased by 27% and the maximum exposure on average by 8.5%. The time to peak plasma concentrations was delayed by 2 hours. The relative increase of bioavailability was considered of no clinical relevance.
The absolute bioavailability of dabigatran following oral administration of dabigatran etexilate was approximately 6.5%.
The oral bioavailability may be increased by 75% after a single dose and 37% at steady state compared to the reference capsule formulation when the pellets are taken without the HPMC capsule shell. Hence, the integrity of the HPMC capsules should always be preserved in clinical use to avoid unintentionally increased bioavailability of dabigatran etexilate. Therefore, patients should be advised not to open the capsules and take the pellets alone (e.g. sprinkled over food or into beverages) (see Section 4.2 Dose and Method of Administration).
A study evaluating post-operative absorption of dabigatran etexilate, 1-3 hours following surgery, demonstrated relatively slow absorption compared with that in healthy volunteers, showing a smooth plasma concentration-time profile without high peak plasma concentrations. Peak plasma concentrations are reached at 6 hours following administration, or at 7 to 9 hours following surgery. It is noted however that contributing factors such as anaesthesia, gastrointestinal paresis and surgical effects will mean that a proportion of patients will experience absorption delay independent of the oral drug formulation. Although this study did not predict whether impaired absorption persists with subsequent doses, it was demonstrated in a further study that slow and delayed absorption is usually only present on the day of surgery. On subsequent days absorption of dabigatran is rapid with peak plasma concentrations attained 2 hours after drug administration.

Distribution.

Low (34-35%) concentration independent binding of dabigatran to human plasma proteins was observed. The volume of distribution of dabigatran of 60-70 L exceeded the volume of total body water indicating moderate tissue distribution of dabigatran.

Metabolism and excretion.

Metabolism and excretion of dabigatran were studied following a single intravenous dose of radiolabelled dabigatran in healthy male subjects. After an intravenous dose, the dabigatran-derived radioactivity was eliminated primarily in the urine (85%). Faecal excretion accounted for 6% of the administered dose. Recovery of the total radioactivity ranged from 88-94% of the administered dose by 168 hours post dose. Dabigatran is eliminated primarily in the unchanged form in the urine, at a rate of approximately 100 mL/min corresponding to the glomerular filtration rate.
After oral administration, dabigatran etexilate is rapidly and completely converted to dabigatran, which is the active form in plasma. The cleavage of the prodrug dabigatran etexilate by esterase-catalysed hydrolysis to the active principle dabigatran is the predominant metabolic reaction. Dabigatran is subject to conjugation forming pharmacologically active acylglucuronides. Four positional isomers, 1-O, 2-O, 3-O, 4-O-acylglucuronide exist, each accounts for less than 10% of total dabigatran in plasma. Traces of other metabolites were only detectable with highly sensitive analytical methods.

Special populations.

Renal impairment.

An open, parallel-group single-centre study compared dabigatran pharmacokinetics in healthy subjects and patients with mild to moderate renal impairment receiving a single dose of dabigatran etexilate 150 mg. Based on pharmacokinetic modeling, estimated exposure to dabigatran increases with the severity of renal function impairment (see Table 32).
Similar findings were observed in the RE-LY study. The median CrCL in RE-LY was 68.4 mL/min. Almost half (45.8%) of the RE-LY patients had a CrCL between 50-80 mL/min. When compared with patients without renal impairment (CrCL ≥ 80 mL/min), patients with moderate renal impairment (CrCL between 30-50 mL/min) had pre- and post-dose dabigatran plasma concentrations 2.29-fold and 1.81-fold higher on average, respectively.
In a small number of volunteers with severe renal insufficiency (CrCL 10-30 mL/min), the exposure (AUC) to dabigatran was approximately 6 times higher and the half-life approximately 2 times longer than that observed in a population without renal insufficiency (see Section 4.2 Dose and Method of Administration; Section 4.3 Contraindications).
Clearance of dabigatran by haemodialysis was investigated in patients with end-stage renal disease (ESRD) without atrial fibrillation. Dialysis was conducted with 700 mL/min dialysate flow rate, four hour duration, a blood flow rate of either 200 mL/min or 350-390 mL/min. This resulted in a removal of 50% or 60% of free or total dabigatran concentrations, respectively. The amount of drug cleared by dialysis is proportional to the blood flow rate. The anticoagulant activity of dabigatran decreased with decreasing plasma concentrations and the PK/PD relationship was not affected by the procedure. Upon cessation of haemodialysis, a redistribution effect of approximately 7% to 15% is seen.
The median CrCL in the RE-COVER study was 100.4 mL/min. 21.7% of patients had mild renal impairment (CrCL > 50- < 80 mL/min) and 4.5% of patients had moderate renal impairment (CrCL between 30-50 mL/min). Patients with mild and moderate renal impairment had on average 1.8-fold and 3.6-fold higher steady-state dabigatran trough concentrations compared with patients with CrCL > 80 mL/min. Similar values for CrCL were found in RE-COVER II.
The median CrCL in the RE-MEDY and RE-SONATE studies were 99.0 mL/min and 99.7 mL/min respectively. 22.9% and 22.5% of the patients had a CrCL > 50- < 80 mL/min, and 4.1% and 4.8% had a CrCL between 30-50 mL/min in the RE-MEDY and RE-SONATE studies.

Elderly patients.

The AUCT,ss and Cmax,ss in male and female elderly subjects (> 65 years) were approximately 1.9-fold and 1.6-fold higher for elderly females compared to young females and 2.2 and 2.0-fold higher for elderly males than in male subjects of 18-40 years of age.
The observed increase of dabigatran exposure correlated with the age related reduction in creatinine clearance. The effect by age on exposure to dabigatran was confirmed in the RE-LY and RE-COVER studies: in RE-LY, compared with subjects aged < 65 years, dabigatran trough concentrations were 28% higher in subjects aged between 65 and 75 years and 68% higher in subjects aged ≥ 75 years. In RE-COVER, compared with patients aged between 50 and < 65 years, dabigatran trough concentrations were 20% and 106% higher in patients aged between 65 and 75 years and ≥ 75 years, respectively (see Section 4.2 Dose and Method of Administration; Section 4.4 Special Warnings and Precautions for Use, Use in the elderly).

Hepatic insufficiency.

No change in dabigatran exposure was seen in 12 subjects in a phase 1 study with moderate hepatic insufficiency (Child-Pugh B) compared to 12 controls.

Prevention of venous thromboembolic events (VTE) in adult patients who have undergone major orthopaedic surgery.

Patients with moderate and severe hepatic impairment (Child-Pugh classification B and C) or liver disease expected to have any impact on survival or with elevated liver enzymes ≥ 2 x upper limit normal (ULN) were excluded in clinical trials.

Prevention of stroke, systemic embolism and reduction of vascular mortality in patients with atrial fibrillation.

Patients with active liver disease including but not limited to the persistent elevation of liver enzymes ≥ 2 x ULN or hepatitis A, B or C were excluded in clinical trials.

Treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

Patients with moderate and severe hepatic impairment (Child-Pugh classification B and C) or liver disease expected to have any impact on survival or with elevated liver enzymes ≥ 2 upper limit normal (ULN) were excluded in clinical trials.

Body weight.

The dabigatran trough concentrations were about 20% lower in subjects with a body weight > 100 kg compared with subjects of 50-100 kg. The dabigatran trough concentrations were about 20% higher in subjects with a body weight < 50 kg compared with subjects of 50-100 kg. Comparing the extremes, < 50 kg versus > 100 kg, the median dabigatran trough concentrations differed by 53%. The majority (80.8%) of the subjects were in the ≥ 50 kg and < 100 kg category with no clear difference detected.

Gender.

Drug exposure in the primary VTE prevention studies was about 1.4 to 1.5-fold (+40% to 50%) higher in female patients. In atrial fibrillation, female patients had on average 1.3-fold (+30%) higher trough and post-dose concentrations. This finding had no clinical relevance.

Ethnic origin.

The pharmacokinetics of dabigatran was investigated in Caucasian and Japanese volunteers after single and multiple doses. Ethnic origin does not affect the pharmacokinetics of dabigatran in a clinically relevant manner. Limited pharmacokinetic data in black patients are available which suggest no relevant differences.

5.3 Preclinical Safety Data

Genotoxicity.

Dabigatran etexilate and its active moiety, dabigatran, were not mutagenic in a bacterial reverse mutation assay (Ames test) and did not induce mutations or chromosome damage in mouse lymphoma cells. Dabigatran etexilate was negative at doses of up to 2000 mg/kg in rats in the mammalian erythrocyte micronucleus test.

Carcinogenicity.

Carcinogenicity studies were performed with dabigatran etexilate in mice and rats for up to 2 years. An increased incidence of granulosa cell tumours without increased incidence of preneoplastic precursor lesions was seen in the ovaries of rats treated at 100 and 200 mg/kg/day (3 and 8 times clinical exposure, respectively based on AUC). 10 adverse event reports referring to ovarian masses or adnexal masses were observed during the RE-LY trial. The mechanism for the ovarian effects in animals is unclear and the long-term effects for humans are unknown, although dabigatran etexilate is not expected to pose a carcinogenic risk to humans. No tumours were seen in rats at 30 mg/kg/day (similar to clinical exposure at the maximum recommended dose) or in studies in mice.

4 Clinical Particulars

4.1 Therapeutic Indications

Prevention of venous thromboembolic events in adult patients who have undergone major orthopaedic surgery of the lower limb (elective total hip or knee replacement). (See Section 4.2 Dose and Method of Administration for details of treatment duration).
Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and at least one additional risk factor for stroke.
Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and for the prevention of recurrent DVT and PE in adults.

4.3 Contraindications

Known hypersensitivity to dabigatran or dabigatran etexilate or to one of the excipients of the product.
Severe renal impairment (CrCL < 30 mL/min).
Haemorrhagic manifestations, patients with a bleeding diathesis, or patients with spontaneous or pharmacological impairment of haemostasis.
Lesion or condition, if considered a significant risk factor for major bleeding. This may include current or recent gastrointestinal ulceration, presence of malignant neoplasms at high risk of bleeding, recent brain or spinal injury, recent brain, spinal or ophthalmic surgery, recent intracranial haemorrhage, known or suspected oesophageal varices, arteriovenous malformations, vascular aneurysms or major intraspinal or intracerebral vascular abnormalities.
Concomitant treatment with any other anticoagulants, e.g. unfractionated heparin (UFH), low molecular weight heparins (enoxaparin, dalteparin, etc.), heparin derivatives (fondaparinux, etc.), oral anticoagulants (warfarin, rivaroxaban, apixaban, etc.) except under the following specific circumstances: switching anticoagulant therapy (see Section 4.2 Dose and Method of Administration), when UFH is given at doses necessary to maintain an open central venous or arterial catheter or when UFH is given during catheter ablation for atrial fibrillation (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
Indwelling spinal or epidural catheter and during the first two hours after removal (see Section 4.4 Special Warnings and Precautions for Use).
Hepatic impairment or liver disease expected to have any impact on survival.
History of intracranial, intraocular, spinal, retroperitoneal or atraumatic intra-articular bleeding.
Gastrointestinal haemorrhage within the past year unless the cause has been permanently eliminated, e.g. by surgery.
Conditions associated with increased risk of bleeding (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk, Table 3: Factors which may increase haemorrhagic risk).
Concomitant treatment with systemic ketoconazole, ciclosporin, itraconazole, dronedarone or the fixed-dose combination glecaprevir/pibrentasvir (see Section 4.4 Special Warnings and Precautions for Use).
Simultaneous initiation of treatment with dabigatran etexilate and oral verapamil.
Treatment initiation with oral verapamil in patients following major orthopaedic surgery who are already treated with dabigatran etexilate.
Prosthetic heart valve replacement.

4.4 Special Warnings and Precautions for Use

Haemorrhagic risk.

Dabigatran etexilate increases the risk of bleeding and can cause significant and sometimes fatal bleeding. As with all anticoagulants, dabigatran etexilate should be used with caution in conditions with an increased risk of bleeding. Bleeding can occur at any site during therapy with dabigatran. An unexplained fall in haemoglobin and/or haematocrit or blood pressure should lead to a search for a bleeding site.
In the case of haemorrhagic complications treatment must be discontinued and the source of bleeding investigated.
For situations of life-threatening or uncontrolled bleeding, when rapid reversal of the anticoagulation effects of dabigatran is required, the specific reversal agent Praxbind (idarucizumab) is available (see Section 4.4 Special Warnings and Precautions for Use, Surgery and interventions, Preoperative phase; Section 4.9 Overdose).
Careful clinical monitoring including renal function testing is required for all patients (see Section 4.2 Dose and Method of Administration, Special patient populations).
Pradaxa does not in general require routine anticoagulation monitoring. However, the measurement of dabigatran related anticoagulation may be helpful to avoid excessive high exposure to dabigatran in the presence of additional risk factors. Coagulation testing should also be considered to assist with the management of patients in the perioperative setting, suspected overdose and emergency situations.
The INR test is unreliable in patients on Pradaxa and false positive INR elevations have been reported. Therefore INR tests should not be performed. Tests of anticoagulant activity such as thrombin time (TT), diluted thrombin time (dTT), ecarin clotting time (ECT) and activated partial thromboplastin time (aPTT) are available to detect excessive dabigatran activity. Dabigatran related anticoagulation can be assessed by ECT or TT. If ECT, dTT or TT are not available, the aPTT test provides an approximation of Pradaxa's anticoagulant activity (see Section 4.4 Special Warnings and Precautions for Use, Effect on laboratory tests). See Table 2.
In atrial fibrillation patients in RE-LY treated with 150 mg twice daily, an aPTT of greater than 2.0-3.0 fold of normal range at trough was associated with an increased risk of bleeding.
Pharmacokinetic studies demonstrated an increase in drug exposure in patients with reduced renal function including age-related decline of renal function. Dabigatran etexilate is contraindicated in cases of severe renal impairment (CrCL < 30 mL/min).
Patients who develop acute renal failure should discontinue dabigatran etexilate.
Factors, such as decreased renal function (30-50 mL/min CrCL), age ≥ 75 years or P-glycoprotein (P-gp) inhibitor co-medication are associated with increased dabigatran plasma levels (see Table 3). The presence of one or more of these factors may increase the risk of bleeding, especially if combined (see Section 4.2 Dose and Method of Administration).
The concomitant use of Pradaxa with the following treatments has not been studied and may increase the risk of bleeding: unfractionated heparins (except at doses necessary to maintain patency of central venous or arterial catheter or during catheter ablation for atrial fibrillation) and heparin derivatives, low molecular weight heparins (LMWH), fondaparinux, desirudin, thrombolytic agents, GPIIb/IIIa receptor antagonists, ticlopidine, dextran, sulfinpyrazone, rivaroxaban, prasugrel, vitamin K antagonists, and P-gp inhibitors such as but not limited to itraconazole, tacrolimus, ciclosporin, ritonavir, tipranavir, nelfinavir and saquinavir (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions, Anticoagulants and platelet aggregation agents).
The concomitant use of Pradaxa with the fixed-dose combination of the P-gp inhibitors glecaprevir/pibrentasvir has been shown to increase exposure of dabigatran and may increase the risk of bleeding (see Section 4.3 Contraindications).
The concomitant use of dronedarone increases exposure of dabigatran and is contraindicated (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
The concomitant use of ticagrelor increases the exposure to dabigatran and may show pharmacodynamic interaction, which may result in an increased risk of bleeding (see Section 4.4 Special Warnings and Precautions for Use, Effect on laboratory tests; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions, Co-medication with P-glycoprotein inhibitors).
Bleeding risk may be increased in patients concomitantly treated with selective serotonin re-uptake inhibitors (SSRI) or selective serotonin norepinephrine re-uptake inhibitors (SNRIs).
The concomitant use of Pradaxa with fibrinolytic treatments has not been studied and may increase the risk of bleeding. The use of fibrinolytic agents for the treatment of acute ischemic stroke may be considered if the patient presents with a thrombin time (TT), or Ecarin clotting time (ECT), or activated partial thromboplastin time (aPTT) not exceeding the upper limit of normal (ULN) according to the local reference range.
Close clinical surveillance (looking for signs of bleeding or anaemia) is recommended throughout the treatment period, especially if risk factors (as summarised in Table 3) are combined. Specifically, with concomitant intake of antiplatelets or strong P-gp inhibitors in patients aged ≥ 75 years, the risk of major bleeding, including gastrointestinal bleeding, increases. If bleeding is clinically suspected, appropriate measures such as testing for occult blood in stool, or testing for a drop in haemoglobin is suggested.
Patients ≥ 75 years of age should not be treated with Pradaxa 150 mg twice a day (see Section 4.2 Dose and Method of Administration, Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation).
NSAIDs (half-lives < 12 hours) given for short-term perioperative analgesia have been shown not to be associated with increased bleeding risk when given in conjunction with dabigatran etexilate. For the 220 mg dose of dabigatran etexilate, the bleeding incidence associated with NSAIDs is 1.5% compared to 1.4% for all patients. Concomitant use of NSAIDs with half-lives greater than 12 hours should be undertaken with caution.
The increase in yearly event rates of major bleeds by concomitant medications in the RE-LY study are shown in Table 4.
Patients taking dabigatran etexilate with PPIs or H2-blockers may be at increased risk of gastrointestinal bleeding due to the associated gastrointestinal conditions for which these drugs are prescribed.

Gastrointestinal bleeds.

Gastrointestinal (GI) haemorrhage occurred at a higher frequency with dabigatran etexilate compared to warfarin (see Section 4.8 Adverse Effects (Undesirable Effects), Table 9). The underlying mechanism of the increased rate of GI bleeding has not been established. Patients with an increased risk of bleeding (e.g. recent gastrointestinal bleeding), should be closely monitored clinically (looking for signs of bleeding or anaemia). In such patients, a dose of 220 mg, given as 110 mg twice daily may be considered. A coagulation test, such as aPTT (see Section 4.4 Special Warnings and Precautions for Use, Effect on laboratory tests), may help to identify patients with an increased bleeding risk caused by excessive dabigatran exposure.

Achlorhydria.

See Section 4.5 Interactions with Other Medicines and Other Forms of Interactions, Co-medication with gastric pH-elevating agents, Pantoprazole, for effect of elevated gastric pH on dabigatran bioavailability.

Myocardial infarction.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation.

In the phase III study RE-LY the overall rate of myocardial infarction (MI) was 0.82, 0.81, and 0.64%/year for dabigatran etexilate 110 mg twice daily, dabigatran etexilate 150 mg twice daily and warfarin, respectively, an increase in relative risk for dabigatran of 29% and 27% compared to warfarin. Irrespective of therapy, the highest absolute risk of MI was seen in the following subgroups, with similar relative risk: patients with previous MI, patients ≥ 65 years with either diabetes or coronary artery disease, patients with left ventricular ejection fraction < 40%, and patients with moderate renal dysfunction. Furthermore a higher risk of MI was seen in patients concomitantly taking ASA plus clopidogrel or clopidogrel alone.

Treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

In the three active controlled studies, a higher rate of MI was reported in patients who received dabigatran etexilate than in those who received warfarin: 0.4% vs. 0.2% in the short-term RE-COVER and RE-COVER II studies; and 0.8% vs. 0.1% in the long-term RE-MEDY trial. The increase was statistically significant in this study (p = 0.022).
In the RE-SONATE study, which compared dabigatran etexilate to placebo, the rate of MI was 0.1% for patients who received dabigatran etexilate and 0.2% for patients who received placebo.

Active cancer patients.

The efficacy and safety have not been established for DVT/PE patients with active cancer.

Interaction with P-glycoprotein inducers.

The concomitant use of dabigatran etexilate with the strong P-gp inducer rifampicin reduces dabigatran plasma concentrations. Other P-gp inducers such as St. John's wort or carbamazepine are also expected to reduce dabigatran plasma concentrations, and should generally be avoided (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Interaction with P-glycoprotein inhibitors.

Coadministration of dabigatran etexilate with strong P-gp inhibitors (amiodarone, clarithromycin, nelfinavir, ritonavir, saquinavir, and verapamil) should be used with caution and close clinical surveillance (looking for signs of active bleeding or anaemia) is required, due to a potential risk of higher plasma levels of dabigatran and consequent potentially exaggerated pharmacodynamic effect of dabigatran etexilate (notably bleeding risk) (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). The concomitant use of dabigatran etexilate with tacrolimus is not recommended. Concomitant use of dabigatran etexilate with ciclosporin, itraconazole, ketoconazole, dronedarone or the fixed-dose combination glecaprevir/pibrentasvir is contraindicated.

Patients with antiphospholipid syndrome.

The safety and efficacy of dabigatran have not been established in patients with antiphospholipid syndrome. In a clinical study, treatment with another direct acting oral anticoagulant (DOAC) was associated with an increased rate of recurrent thrombotic events compared with a vitamin K antagonist (VKA) in patients with a history of thrombosis who are diagnosed with antiphospholipid syndrome and are persistently triple positive. DOACs including dabigatran etexilate are not recommended for patients with a history of thrombosis who are diagnosed with antiphospholipid syndrome. In particular for patients that are triple positive (for lupus anticoagulant, anticardiolipin antibodies, and anti-beta 2-glycoprotein I antibodies), treatment with DOACs could be associated with increased rates of recurrent thrombotic events compared with vitamin K antagonist therapy.

Pulmonary.

Acute pulmonary embolus in haemodynamically unstable patients, or in those requiring thrombolysis or pulmonary embolectomy.

Safety and efficacy of Pradaxa have not been established for the treatment of VTE in patients with pulmonary embolus who are haemodynamically unstable, or who may receive thrombolysis or pulmonary embolectomy. In these patients the initial anticoagulation therapy should exclude the use of Pradaxa.

Surgery and interventions.

Patients on dabigatran etexilate who undergo surgery or invasive procedures are at increased risk for bleeding. Therefore surgical interventions may require the temporary discontinuation of dabigatran etexilate.
Patients can stay on Pradaxa while being cardioverted. Pradaxa treatment (150 mg twice daily) does not need to be interrupted in patients undergoing catheter ablation for atrial fibrillation. There are no clinical data on continuation of Pradaxa treatment during catheter ablation in those non-valvular atrial fibrillation patients receiving 110 mg twice daily (see Section 4.2 Dose and Method of Administration).
Caution should be exercised when treatment is temporarily discontinued for interventions and anticoagulant monitoring is warranted. Clearance of dabigatran in patients with renal insufficiency may take longer (see Section 5.2 Pharmacokinetic Properties, Tables 31 and 32). This should be considered in advance of any procedures. In such cases a coagulation test (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk, Effect on laboratory tests; Section 5.1 Pharmacodynamic Properties, Mechanism of action) may help to determine whether haemostasis is still impaired.
In case of emergency surgery or urgent procedures when rapid reversal of the anticoagulant effect is required the specific reversal agent Praxbind (idarucizumab) for Pradaxa is available.
Reversing dabigatran therapy exposes patients to the thrombotic risk of their underlying disease. Pradaxa treatment can be re-initiated 24 hours after administration of Praxbind (idarucizumab), if the patient is clinically stable and adequate haemostasis has been achieved.

Preoperative phase.

Due to an increased risk of bleeding dabigatran etexilate may be stopped temporarily in advance of invasive or surgical procedures.

Emergency surgery or urgent procedure.

Dabigatran etexilate should be temporarily discontinued. The specific reversal agent (Praxbind, idarucizumab) of Pradaxa is available for the rapid reversal of the anticoagulation effect (see Section 4.4 Special Warnings and Precautions for Use, Surgery and interventions).
Reversing dabigatran therapy exposes patients to the thrombotic risk of their underlying disease. Pradaxa treatment can be re-initiated 24 hours after administration of Praxbind (idarucizumab), if the patient is clinically stable and adequate haemostasis has been achieved.

Elective surgery/intervention.

If possible, dabigatran etexilate should be discontinued at least 24 hours before invasive or surgical procedures. In patients at higher risk of bleeding or in major surgery where complete haemostasis may be required, consider stopping dabigatran etexilate 2-4 days before surgery. Clearance of dabigatran in patients with renal insufficiency may take longer. This should be considered in advance of any procedures (see Table 5).
Dabigatran etexilate is contraindicated in patients with severe renal dysfunction (CrCL < 30 mL/min) but should this occur then dabigatran etexilate should be stopped at least 5 days before major surgery.

Acute surgery/intervention.

Dabigatran etexilate should be temporarily discontinued. An acute surgery/ intervention should be delayed if possible until at least 12 hours after the last dose. If surgery cannot be delayed there may be an increase in the risk of bleeding. This risk of bleeding should be weighed against the urgency of intervention.

Spinal anaesthesia/epidural anaesthesia/lumbar puncture.

Procedures such as spinal anaesthesia may require complete haemostatic function. In patients treated with dabigatran etexilate and who undergo spinal or epidural anaesthesia, or in whom lumbar puncture is performed in follow-up to surgery, the formation of spinal or epidural haematomas that may result in long-term or permanent paralysis cannot be excluded.
The risk of spinal or epidural haematoma may be increased in cases of traumatic or repeated puncture and by the prolonged postoperative use of epidural catheters. After removal of a catheter, an interval of at least 2 hours should elapse before the administration of the first dose of dabigatran etexilate. These patients require frequent observation for neurological signs and symptoms.

Post-procedural period.

Pradaxa treatment can be resumed / started after complete haemostasis is achieved.

Hip fracture surgery.

There is no data on the use of dabigatran etexilate in patients undergoing hip fracture surgery. Therefore treatment is not recommended.

Trauma.

Patients who are at increased risk of trauma accidents or surgery may have a higher risk of traumatic bleeding.

Body weight.

Limited data in patients < 50 kg are available (see Section 5.2 Pharmacokinetic Properties, Special populations, Body weight).

Use in hepatic impairment.

Patients with liver disease expected to have any impact on survival or with elevated liver enzymes > 2 upper limit normal (ULN) were excluded in clinical trials. Therefore the use of dabigatran etexilate is contraindicated in this population. A liver function test is recommended prior to initiating treatment.

Use in renal impairment.

Pharmacokinetic studies demonstrated up to a 3-fold increase in drug exposure in patients with reduced renal function including age related decline of renal function (see Section 5.2 Pharmacokinetic Properties).
In patients with mild renal impairment increases in dabigatran concentration were observed (see Section 5.2 Pharmacokinetic Properties, Special populations, Renal impairment, Table 32).
In patients with moderate renal impairment in RE-LY, the observed major bleeding rate was comparable between dabigatran 110 mg and 150 mg (dabigatran 110 mg 5.65%/year versus dabigatran 150 mg 5.27%/year versus warfarin 5.68%/year). Based on theoretical considerations of drug exposure a reduced dose may be considered in these patients (see Section 4.2 Dose and Method of Administration).
The presence of one or more factors known to increase haemorrhagic risk (see Table 3) may increase the risk of bleeding. Caution should be exercised. Close clinical surveillance is recommended.
Dabigatran etexilate is contraindicated in cases of severe renal impairment (CrCL < 30 mL/min).
Patients who develop acute renal failure should discontinue dabigatran etexilate.

Use in the elderly.

The clinical studies have been conducted in a patient population with a mean age > 65 years. Patients should be treated with the dose of dabigatran etexilate as recommended, see Section 4.2 Dose and Method of Administration. Pharmacokinetic studies in older subjects demonstrate an increase in drug exposure in those patients with age-related decline of renal function (see Section 4.4 Special Warnings and Precautions for Use, Use in renal impairment). The risk of stroke is higher in the elderly, however the risk of bleeding increases with increasing age (see Table 27). Careful clinical observation is advised and a dosage adjustment is recommended in elderly patients (≥ 75 years) due in part to age related impairment of renal function (see Table 3). These patients should be treated with caution (see Section 4.2 Dose and Method of Administration), particularly if they are also taking a drug which is a P-glycoprotein inhibitor (see Section 4.4 Special Warnings and Precautions for Use, Interaction with P-glycoprotein inhibitors).

Paediatric use.

There is no experience in children. Dabigatran etexilate has not been investigated in patients < 18 years of age. Treatment of children with dabigatran etexilate is not recommended.

Effect on laboratory tests.

The aPTT test may be useful in determining an excess of anticoagulant activity. Dabigatran concentration exceeding 450-500 nanogram/mL would result in an aPTT of greater than 2.5 times control. An aPTT greater than 2.5 times control is suggestive of excess anticoagulation (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk; Section 5.1 Pharmacodynamic Properties).

4.5 Interactions with Other Medicines and Other Forms of Interactions

Interaction studies have only been performed in adults.

Anticoagulants and platelet aggregation agents.

The following treatments are not recommended concomitantly with dabigatran etexilate: unfractionated heparins and heparin derivatives, low molecular weight heparins (LMWH), and heparin derivatives (fondaparinux, desirudin), thrombolytic medicinal products, and vitamin K antagonists, rivaroxaban, apixaban or other oral anticoagulants, and platelet aggregation medicinal products such as GPIIb/IIIa receptor antagonists, clopidogrel, ticlopidine, prasugrel, ticagrelor, dextran, and sulfinpyrazone.
From the limited data collected in the phase III study RE-LY in patients with atrial fibrillation it was observed that the concomitant use of other oral or parenteral anticoagulants increases major bleeding rates with both dabigatran etexilate and warfarin by approximately 2.5-fold, mainly related to situations when switching from one anticoagulant to another.
Unfractionated heparin can be administered at doses necessary to maintain a patent central venous or arterial catheter or during catheter ablation for atrial fibrillation (see Section 4.2 Dose and Method of Administration; Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk).

Enoxaparin.

The switch from enoxaparin to dabigatran has been clinically tested in a phase I study. After 3 days treatment of once daily 40 mg enoxaparin s.c., dabigatran exposure was slightly lower 24 hours following the last dose of enoxaparin than after administration of dabigatran etexilate (single dose of 220 mg) alone. A higher anti-FXa/FIIa activity was observed after dabigatran administration with enoxaparin pre-treatment compared to that after treatment with dabigatran alone, which was considered to be due to the carry-over effect of enoxaparin treatment. The other dabigatran related anti-coagulation tests, i.e. aPTT, ECT and TT, were mainly not affected after a 24 hour washout of enoxaparin.

Interactions linked to dabigatran etexilate and dabigatran metabolic profile.

Dabigatran etexilate and dabigatran are not metabolised by the cytochrome P450 system and had no in vitro effects on human cytochrome P450 enzymes. This has been confirmed by in vivo studies with healthy volunteers, who did not show any interaction between this treatment and the following drugs: atorvastatin (CYP3A4) and diclofenac (CYP2C9). Therefore, related medicinal product interactions are not expected with dabigatran.

Atorvastatin.

When dabigatran etexilate was coadministered with atorvastatin, exposure of atorvastatin, atorvastatin metabolites and of dabigatran were unchanged indicating a lack of interaction.

Diclofenac.

When dabigatran etexilate was coadministered with diclofenac, the plasma exposure of both medicinal products remained unchanged indicating a lack of a pharmacokinetic interaction between dabigatran etexilate and diclofenac. However, due to the risk of haemorrhage, notably with NSAIDs with elimination half-lives > 12 hours, close observation for signs of bleeding is recommended (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk).

P-glycoprotein inhibitors/inducers.

The pro-drug dabigatran etexilate but not dabigatran is a substrate of the efflux transporter P-gp. Therefore, co-administration of dabigatran etexilate and a P-gp inhibitor or inducer may alter the plasma dabigatran concentration. Co-medications with P-gp transporter inhibitors and inducers have been investigated.

Co-medication with P-glycoprotein inhibitors.

Dabigatran etexilate is a substrate for the efflux transporter P-gp. Concomitant administration of P-gp inhibitors (such as amiodarone, verapamil, quinidine, systemic ketoconazole, dronedarone, ticagrelor, clarithromycin and the fixed-dose combination glecaprevir/pibrentasvir) is expected to result in increased dabigatran plasma concentrations.

Amiodarone.

When dabigatran etexilate was coadministered with a single dose of 600 mg amiodarone, the extent and rate of absorption of amiodarone and its active metabolite DEA were essentially unchanged. The dabigatran AUC and Cmax were increased by about 1.6-fold and 1.5-fold (+60% and 50%), respectively. In the population pharmacokinetics study from RE-LY, no important changes in dabigatran trough levels were observed in patients who received amiodarone.
In patients in the RE-LY study concentrations were increased by no more than 14%.
The mechanism of the interaction has not been completely clarified. In view of the long half-life of amiodarone the potential for drug interaction may exist for weeks after discontinuation of amiodarone.

Dronedarone.

When dabigatran etexilate and dronedarone were given at the same time total dabigatran AUC0-∞ and Cmax values increased by about 2.4-fold and 2.3-fold (+136% and 125%), respectively, after multiple dosing of 400 mg dronedarone bid, and about 2.1-fold and 1.9-fold (+114% and 87%), respectively, after a single dose of 400 mg. The terminal half-life and renal clearance of dabigatran were not affected by dronedarone. When single and multiple doses of dronedarone were given 2 hours after dabigatran etexilate, the increases in dabigatran AUC0-∞ were 1.3-fold and 1.6-fold, respectively.

Verapamil.

When dabigatran etexilate was coadministered with oral verapamil, the Cmax and AUC of dabigatran were increased depending on timing of administration and formulation of verapamil.
The greatest elevation of dabigatran exposure was observed with the first dose of an immediate release formulation of verapamil administered one hour prior to dabigatran etexilate intake (increase of Cmax by about 2.8-fold (+180%) and AUC by about 2.5-fold (+150%)). The effect was progressively decreased with administration of an extended release formulation (increase of Cmax by about 1.9-fold (+90%) and AUC by about 1.7-fold (+70%)) or administration of multiple doses of verapamil (increase of Cmax by about 1.6-fold (+60%) and AUC by about 1.5-fold (+50%)). This can be explained by the induction of P-gp in the gut by chronic verapamil treatment.
There was no meaningful interaction observed when verapamil was given 2 hours after dabigatran etexilate (increase of Cmax by about 10% and AUC by about 20%). This is explained by completed dabigatran absorption after 2 hours.
No data are available for the parenteral application of verapamil; based on the mechanism of the interaction, no meaningful interaction is expected.
In the RE-LY study, patients treated concomitantly with verapamil had on average a 16% higher trough dabigatran plasma concentration and a 20% higher 2 hours post-dose dabigatran plasma concentration only, compared to patients who were not on concomitant verapamil. Accordingly, the annualised bleeding rates in patients who had used verapamil at least once together with warfarin, dabigatran etexilate 110 mg twice daily or 150 mg twice daily were 3.33%, 3.09% and 3.92%, respectively.
In the population pharmacokinetics study from RE-LY, no important changes in dabigatran trough levels were observed in patients who received verapamil.

Clarithromycin.

When clarithromycin 500 mg bid was administered together with dabigatran etexilate no clinically relevant PK-interaction was observed (increase of Cmax by about 15% and AUC by about 19%).

Ketoconazole.

Systemic ketoconazole increased total dabigatran AUC0-∞ and Cmax values by about 2.4-fold (+138% and 135%), respectively, after a single dose of 400 mg, and about 2.5-fold (+153% and 149%), respectively, after multiple dosing of 400 mg ketoconazole once daily. The time to peak, terminal half-life and mean residence time were not affected by ketoconazole. Concomitant administration of systemic ketoconazole is contraindicated.

Quinidine.

Quinidine was given as 200 mg dose every 2nd hour up to a dose of 1000 mg. Dabigatran etexilate was given twice daily over 3 consecutive days, on the 3rd day with or without quinidine. Dabigatran AUCT,ss and Cmax,ss were increased on average by about 1.5-fold (+53% and 56%), respectively with concomitant quinidine.

Ticagrelor.

When a single dose of 75 mg dabigatran etexilate was coadministered simultaneously with a loading dose of 180 mg ticagrelor, the total dabigatran AUC and Cmax were increased by 1.73-fold and 1.95-fold (+73% and 95%), respectively. After multiple doses of ticagrelor 90 mg twice daily, and following a single dose of 75 mg dabigatran etexilate, the increase of total dabigatran exposure was reduced to 1.56-fold and 1.46-fold (+56% and 46%) for Cmax and AUC, respectively.
Concomitant administration of a loading dose of 180 mg ticagrelor and 110 mg dabigatran etexilate (in steady state) increased the dabigatran AUCT,ss and Cmax,ss by 1.49-fold and 1.65-fold (+49% and 65%), respectively, compared with dabigatran etexilate given alone. When a loading dose of 180 mg ticagrelor was given 2 hours after 110 mg dabigatran etexilate (in steady state), the increase of dabigatran AUCT,ss and Cmax,ss was reduced to 1.27-fold and 1.23-fold (+27% and 23%), respectively, compared with dabigatran etexilate given alone. This staggered intake is the recommended administration for start of ticagrelor with a loading dose. Concomitant administration of 90 mg ticagrelor BID (maintenance dose) with 110 mg dabigatran etexilate increased the adjusted dabigatran AUCT,ss and Cmax,ss 1.26-fold and 1.29-fold, respectively, compared with dabigatran etexilate given alone.

Co-medication with P-glycoprotein inducers.

Rifampicin.

Pre-dosing of the probe inducer rifampicin at a dose of 600 mg once daily for 7 days decreased total dabigatran peak and total exposure by 65.5% and 67%, respectively. The inducing effect was diminished resulting in dabigatran exposure close to the reference by day 7 after cessation of rifampicin treatment. No further increase in bioavailability was observed after another 7 days.
The concomitant use of Pradaxa with P-gp inducers (e.g. rifampicin) reduces exposure to dabigatran and should generally be avoided.

Co-medication with P-glycoprotein substrates.

Digoxin.

When dabigatran etexilate was coadministered with digoxin, no changes to digoxin plasma levels and no clinically relevant changes to dabigatran exposure have been observed.

Co-medication with platelet inhibitors.

Acetylsalicylic acid (ASA, aspirin).

The effect of concomitant administration of dabigatran etexilate and ASA on the risk of bleeds was studied in patients with atrial fibrillation in a phase II study in which randomised ASA coadministration was applied. Based on logistic regression analysis, co-administration of ASA and 150 mg dabigatran etexilate twice daily may increase the risk for any bleeding from 12% to 18% and 24% with 81 mg and 325 mg ASA, respectively.
From the data gathered in the phase III study RE-LY it was observed that ASA or clopidogrel co-medication with dabigatran etexilate at dosages of 110 mg or 150 mg twice daily may increase the risk of major bleeding. The higher rate of bleeding events by ASA or clopidogrel co-medication was, however, also observed for warfarin (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk, Table 4).
NSAIDs given for short-term perioperative analgesia have been shown not to be associated with increased bleeding risk when given in conjunction with dabigatran etexilate. There is limited evidence regarding the use of regular NSAID medication with half-lives of less than 12 hours during treatment with dabigatran etexilate and this has not suggested additional bleeding risk.
NSAIDs increased the risk of bleeding in RE-LY in all treatment groups.

Clopidogrel.

In a phase I study in young healthy male volunteers, the concomitant administration of dabigatran etexilate and clopidogrel resulted in no further prolongation of capillary bleeding times (CBT) compared to clopidogrel monotherapy. In addition, dabigatran AUCT,ss and Cmax,ss and the coagulation measures for dabigatran effect, aPTT, ECT or TT (anti-FIIa), or the inhibition of platelet aggregation (IPA) as measure of clopidogrel effect remained essentially unchanged comparing combined treatment and the respective monotreatments. With a loading dose of 300 or 600 mg clopidogrel, dabigatran AUCt,ss and Cmax,ss were increased by about 1.3 to 1.4-fold (+30% to 40%) (see Acetylsalicylic acid (ASA, aspirin) section above).

Antiplatelets or other anticoagulants.

The concomitant use of dabigatran etexilate and antiplatelets or other anticoagulants may increase the risk of bleeding. See Acetylsalicylic acid (ASA, aspirin), Clopidogrel sections above.

Co-medication with selective serotonin re-uptake inhibitors (SSRIs).

SSRIs increased the risk of bleeding in RE-LY in all treatment groups.

Co-medication with gastric pH-elevating agents.

Pantoprazole.

When dabigatran etexilate was coadministered with pantoprazole, a decrease in dabigatran area under the plasma concentration-time curve of approximately 30% was observed. Pantoprazole and other proton-pump inhibitors (PPIs) were co-administered with dabigatran etexilate in clinical trials and no effects on bleeding or efficacy were observed.

Ranitidine.

Ranitidine administration together with dabigatran etexilate had no meaningful effect on the extent of absorption of dabigatran.
The changes in dabigatran exposure determined by population pharmacokinetic analysis caused by PPIs and antacids were not considered clinically relevant because the magnitude of the effect was minor (fractional decrease in bioavailability not significant for antacids and 14.6% for PPIs).
In the phase III study RE-LY PPI co-medication did not result in lower trough levels and on average only slightly reduced post-dose concentrations (-11%). Accordingly, PPI comedication seemed to not be associated with a higher incidence of stroke or systemic embolism, especially in comparison with warfarin, and hence, the reduced bioavailability by pantoprazole co-administration seemed to be of no clinical relevance. An increased risk of bleeding with PPIs and H2-antagonists was observed for both the dabigatran and warfarin treatment groups (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk, Table 4). Patients taking PPIs or H2-blockers may be at increased risk of gastrointestinal bleeding due to the associated gastrointestinal conditions for which these drugs are prescribed.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Rat fertility was unaffected by treatment with dabigatran etexilate at oral doses of up to 200 mg/kg/day (approximately 4-5 times clinical exposure, based on AUC). There was a significant decrease in the number of implantations at 70 and 200 mg/kg/day (3 and 4 times clinical exposure, respectively based on AUC), which was associated with an increase in pre-implantation loss. The effect on human fertility is unknown.
(Category C)
Anticoagulants and thrombolytic agents can produce placental haemorrhage and subsequent prematurity and foetal loss. There are no adequate and well-controlled studies in pregnant women. It is not known whether dabigatran etexilate can cause foetal harm when administered to pregnant women. Dabigatran etexilate should not be used during pregnancy.
Studies in rats have shown that small amounts of dabigatran and/or its metabolites cross the placenta.
Embryofoetal development studies with oral dabigatran etexilate showed delayed ossification and general disturbances in foetal development of rats at 15 and 70 mg/kg/day (1 to 4-fold anticipated human exposure based on AUC). The delayed ossification, however, was transient, since offspring of rats treated with 15, 30 and 70 mg/kg/day during gestation and lactation showed normal body weights, normal body weight development, normal survival after birth and normal physical postnatal development. Morphogenic effects such as cleft thoracal vertebral body (rats) and dilated cerebral ventricles (rabbits) were seen at a maternotoxic dose of 200 mg/kg/day (relative exposure of 8 and 13, respectively). Maternal toxicity in rats at > 70 mg/kg/day was associated with an increased rate of resorptions, and a significant decrease in viable foetuses was seen at 200 mg/kg/day. In rats allowed to deliver, mortality due to excessive vaginal bleeding was seen at 70 mg/kg/day and in one dam at 15 mg/kg/day. An increase in post-implantation loss was seen at 70 mg/kg/day in these animals.
Dabigatran and/or its metabolites were present in the milk of lactating rats given oral doses of dabigatran etexilate. The ratio of the dabigatran concentration in rat milk to that in the plasma of the mothers was 0.4. No clinical data are available. As a precaution, use of dabigatran etexilate is not recommended in women who are breast-feeding.

4.8 Adverse Effects (Undesirable Effects)

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at https://www.tga.gov.au/reporting-problems.
The safety of Pradaxa has been evaluated overall in 38,141 patients treated in 11 clinical trials; thereof 23,393 Pradaxa patients were investigated.
In the primary VTE prevention trials after major orthopaedic surgery a total of 10,795 patients were treated in 6 controlled studies with at least one dose of dabigatran etexilate (150 mg qd, 220 mg qd) or enoxaparin. 6,684 of the 10,795 patients were treated with 150 or 220 mg once daily of dabigatran etexilate.
In the RE-LY trial investigating the prevention of stroke and systemic embolism in patients with atrial fibrillation a total of 12,042 patients were treated with dabigatran etexilate. Of these 6,059 were treated with 150 mg twice daily of dabigatran etexilate, while 5,983 received doses of 110 mg twice daily.
In the acute DVT/PE treatment trials (RE-COVER, RE-COVER II) a total of 2,553 patients were included in the safety analysis for dabigatran etexilate. All patients were treated with dabigatran etexilate 150 mg twice daily.
In the recurrent DVT/PE prevention trials (RE-MEDY, RE-SONATE) a total of 2,114 patients were treated with dabigatran etexilate. Of these, 552 were rolled over from the RE-COVER trial (acute DVT/PE treatment) into the RE-MEDY trial and are counted in both the acute and recurrent patient totals. All patients were treated with dabigatran etexilate 150 mg twice daily.
In total, about 9% of patients treated for elective hip or knee surgery (short-term treatment for up to 42 days), 22% of patients with atrial fibrillation treated for the prevention of stroke and systemic embolism (long-term treatment for up to 3 years), 14% of patients treated for acute DVT/PE treatment (long-term treatment up to 6 months) and 15% of patients treated for recurrent DVT/PE prevention (long-term treatment up to 36 months) experienced adverse reactions.

Bleeding.

Bleeding is the most relevant adverse reaction of Pradaxa. Depending on the indication treated, bleeding of any type or severity occurred in approximately 14% of patients treated short-term for elective hip or knee replacement surgery, in 16.6% yearly of AF patients treated long-term for the prevention of stroke and systemic embolism and in 14.4% of patients with acute DVT and/or PE. In the recurrent DVT/PE trial RE-MEDY 19.4% and in the RE-SONATE trial 10.5% of patients experienced any bleeding.
Although rare in frequency in clinical trials, major or severe bleeding may occur and, regardless of location, may lead to disabling, life-threatening or even fatal outcomes.

Prevention of venous thromboembolic events (VTE) in adult patients who have undergone major orthopaedic surgery.

A total of 10,795 patients were treated in 6 controlled VTE prevention trials with at least one dose of dabigatran etexilate (150 mg qd, 220 mg qd) or enoxaparin. 6,684 of the 10,795 patients were treated with 150 or 220 mg daily of dabigatran etexilate.
The adverse reactions that can with reasonable certainty be attributed to dabigatran, and occurred with a similar frequency with enoxaparin, are those of bleeding or signs of bleeding, e.g. anaemia and wound discharge. The definition of major bleeding events (MBE) followed the International Society on Thrombosis and Haemostasis (ISTH) criteria and the EMEA guideline.
According to the MedDRA coding system, bleeding events are distributed over several system organ classes (SOC); therefore, a summary description of major and any bleeding is given in Table 6.
Table 6 shows the number (%) of patients experiencing major and total bleeding event rates during the treatment period in the VTE prevention randomised clinical trials, according to dose.
Overall bleeding rates were similar between treatment groups and not significantly different.
Adverse events classified by system organ class (SOC) and preferred terms reported ≥ 1% from any treatment group of all 6 controlled VTE prevention studies are shown in Table 7.
Adverse reactions observed with exposure to dabigatran etexilate 150 mg daily and 220 mg daily from all 6 controlled VTE prevention studies are listed below by system organ class and frequency according to the following categories: common ≥ 1% and < 10%, uncommon ≥ 0.1% and < 1%, rare ≥ 0.01% and < 0.1%.

Blood and lymphatic system disorders.

Uncommon: anaemia.
Rare: thrombocytopenia.

Immune system disorders.

Uncommon: drug hypersensitivity (including drug hypersensitivity, pruritus, rash, urticaria, bronchospasm).
Rare: angioedema.
Not known: anaphylactic reaction.

Nervous system disorders.

Rare: intracranial haemorrhage.

Vascular disorders.

Uncommon: haematoma, wound haemorrhage.
Rare: haemorrhage, bloody discharge.

Respiratory, thoracic and mediastinal disorders.

Uncommon: epistaxis.
Rare: haemoptysis.

Gastrointestinal disorders.

Uncommon: gastrointestinal haemorrhage, diarrhoea, nausea, vomiting.
Rare: abdominal pain, dyspepsia, dysphagia, gastrointestinal ulcer, gastrooesophagitis, gastrooesophageal reflux disease.

Hepatobiliary disorders.

Common: hepatic function abnormal.

Skin and subcutaneous tissue disorders.

Uncommon: skin haemorrhage.

Musculoskeletal, connective tissue and bone disorders.

Uncommon: haemarthrosis.

Renal and urinary disorders.

Uncommon: urogenital haemorrhage, haematuria.

General disorders and administration site conditions.

Rare: injection site haemorrhage, catheter site haemorrhage.

Injury, poisoning and procedural complications.

Uncommon: traumatic haemorrhage, post procedural haematoma, post procedural haemorrhage, wound secretion.
Rare: incision site haemorrhage, anaemia postoperative, post procedural discharge.

Surgical and medical procedures.

Rare: wound drainage, post procedural drainage.
See Table 8.
The pattern of adverse events for RE-NOVATE II (1160.64) was similar to RE-NOVATE (1160.48).
For RE-NOVATE II (1160.64), the incidence of MBEs was 1.4% for patients in the dabigatran etexilate 220 mg group and 0.9% for patients in the enoxaparin 40 mg group (p = 0.4022). For any bleeding event the incidence was 9.7% for patients in the dabigatran group compared with 8.3% for patients in the enoxaparin group (p = 0.2626). In both treatment groups most elevated LFTs occurred in the immediate post-operative period, during the first 10 days of treatment with trial medication, and most were transient. The estimated cumulative incidence of an ALT value > 3 x ULN from surgery up to Day 10 was 3.1% for dabigatran patients and to the end of the trial it was 3.6%. Corresponding figures for enoxaparin showed a slightly higher cumulative incidence: 5.0% to Day 10 and 5.4% to the end of the trial. ALT elevations > 10 x ULN were higher for dabigatran patients (0.4%) than enoxaparin patients (0.1%). Three patients (all dabigatran group) had alanine transaminase (ALT) elevations above 3 x the upper limit of the normal range (ULN) in combination with elevated bilirubin values above 2 x ULN. In two of these three patients alternative explanations (viral hepatitis) were reported.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation.

Two doses (110 mg and 150 mg twice daily) of dabigatran etexilate were compared to warfarin in the RE-LY study (Randomised Evaluation of Long-term anticoagulant therapy), the Phase III trial in the prevention of thromboembolic stroke and systemic embolism for safety in more than 18,000 atrial fibrillation patients with a median duration of 20 months.

Drug discontinuation.

Over the course of the trial, the total number of patients with adverse events leading to treatment discontinuation was 19% for dabigatran etexilate 110 mg, 20.5% for dabigatran etexilate 150 mg and 15.6% for warfarin. The most frequent adverse events leading to discontinuation were gastrointestinal events.

Bleeding definitions.

In the RE-LY study, bleeding was classified as major using the following guidelines.
Major bleeding fulfilled one or more of the following criteria:
bleeding associated with a reduction in haemoglobin of at least 20 grams per litre or leading to a transfusion of at least 2 units of blood or packed cells;
symptomatic bleeding in a critical area or organ: intraocular, intracranial, intraspinal or intramuscular with compartment syndrome, retroperitoneal bleeding, intra-articular bleeding or pericardial bleeding.
Major bleeds were classified as life-threatening if they fulfilled one or more of the following criteria:
fatal bleed; symptomatic intracranial bleed; reduction in haemoglobin of at least 50 grams per litre; transfusion of at least 4 units of blood or packed cells; a bleed associated with hypotension requiring the use of intravenous inotropic agents; a bleed that necessitated surgical intervention.

Bleeding.

Table 9 shows the number of patients experiencing major and total bleeding event rates during the treatment period in the RE-LY study, with the yearly bleeding rate in (%). Both dabigatran etexilate doses were associated with a lower yearly event rate for life threatening bleeds, intracranial haemorrhage and any bleeds as compared with warfarin treatment. Subjects randomised to dabigatran etexilate 110 mg twice daily had a significantly lower risk for major bleeds compared with warfarin (hazard ratio 0.81 [p = 0.0027]).
In Table 9, the category of major bleeds includes both life-threatening and non-life threatening bleeds. Within life-threatening, intracranial bleeds are a subcategory of life threatening bleeds. Intracranial bleeds include intracerebral (haemorrhagic stroke), subarachnoid and subdural bleeds. For this reason, these events may be counted in multiple categories. See Table 10.
The risk of major bleeding with dabigatran etexilate 110 mg and 150 mg was consistent across all major subgroups of baseline characteristics with the exception of age. There was a higher risk of bleeding with dabigatran etexilate 150 mg in patients ≥ 75 years of age (hazard ratio vs. warfarin (95% CI) 1.19 (0.99, 1.43)).

GI/dyspepsia.

Dabigatran etexilate subjects had the highest incidence of GI AEs (34.6%, 34.5%, and 24.0% for dabigatran etexilate 110 mg, dabigatran etexilate 150 mg, and warfarin, respectively). Additional GI events that were reported more frequently with dabigatran etexilate treatment included upper abdominal pain, gastritis, abdominal discomfort, gastroesophageal reflux disease, dysphagia, and flatulence (Table 11). There was no consistent dose-response relationship with respect to GI AEs.

Liver function tests.

In the RE-LY study, potential abnormalities of liver function tests (LFT) occurred with a comparable or lower incidence in dabigatran etexilate vs. warfarin treated patients (see Table 12).

Myocardial infarction.

There was an increased frequency in myocardial infarction events in subjects treated with dabigatran etexilate compared to warfarin treated subjects which was not statistically significant (yearly event rate: 150 mg twice daily 0.81%, 110 mg twice daily 0.82%, warfarin 0.64%) (see Section 4.4 Special Warnings and Precautions for Use).

Overview of adverse events from RE-LY.

The incidence of AEs was similar between subjects treated with dabigatran etexilate 110 mg twice daily and dabigatran etexilate 150 mg twice daily (78.6% and 78.3%, respectively) versus 75.9% of subjects treated with warfarin. The incidence of SAEs was similar across treatment groups. However, dabigatran etexilate subjects had a lower incidence of fatal AEs, life-threatening AEs, and events that required hospitalisation as compared to warfarin subjects.
Adverse events classified by system organ class and preferred terms reported ≥ 2% from any treatment group of the RE-LY study are shown in Table 13. Diarrhoea, dyspepsia, and nausea were the most frequently reported GI AEs, all of which were reported at a higher frequency with dabigatran etexilate 110 mg and dabigatran etexilate 150 mg treatment, particularly for dyspepsia (6.2%, 5.7%, and 1.4% for dabigatran etexilate 110 mg, dabigatran etexilate 150 mg, and warfarin, respectively).
Adverse reactions observed with exposure to dabigatran 110 mg twice daily and 150 mg twice daily during the RE-LY trial are listed below by system organ class and frequency according to the following categories: common ≥ 1% and < 10%, uncommon ≥ 0.1% and < 1%, rare ≥ 0.01% and < 0.1%.

Blood and lymphatic system disorders.

Common: anaemia.
Uncommon: thrombocytopenia.

Immune system disorders.

Uncommon: drug hypersensitivity (including drug hypersensitivity, pruritus, rash, urticaria, bronchospasm).
Rare: angioedema.
Not known: anaphylactic reaction.

Nervous system disorders.

Uncommon: intracranial haemorrhage.

Vascular disorders.

Uncommon: haematoma, haemorrhage.

Respiratory, thoracic and mediastinal disorders.

Common: epistaxis.
Uncommon: haemoptysis.

Gastrointestinal disorders.

Common: gastrointestinal haemorrhage, abdominal pain, diarrhoea, dyspepsia, nausea.
Uncommon: dysphagia, gastrointestinal ulcer, gastrooesophagitis, gastrooesophageal reflux disease, vomiting.

Hepatobiliary disorders.

Uncommon: hepatic function abnormal.

Skin and subcutaneous tissue disorders.

Common: skin haemorrhage.

Musculoskeletal and connective tissue disorders.

Rare: haemarthrosis.

Renal and urinary disorders.

Common: urogenital haemorrhage, haematuria.

General disorders and administration site conditions.

Rare: catheter site haemorrhage, injection site haemorrhage.

Injury, poisoning and procedural complications.

Rare: traumatic haemorrhage, incision site haemorrhage.

Treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

Bleeding.

Table 14 shows bleeding events in the pooled pivotal studies RE-COVER and RE-COVER II testing the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE).
Bleeding events for both treatments are counted from the first intake of dabigatran etexilate or warfarin after the parenteral therapy has been discontinued (oral only treatment period). This includes all bleeding events which occurred during dabigatran therapy. All bleeding events which occurred during warfarin therapy are included except for those during the overlap period between warfarin and parenteral therapy.
The definition of major bleeding events (MBEs) followed the recommendations of the International Society on Thrombosis and Haemostasis. A bleeding event was categorised as an MBE if it fulfilled at least one of the following criteria.
Fatal bleeding.
Symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular, retroperitoneal, intra-articular, or pericardial, or intramuscular with compartment syndrome. In order for bleeding in a critical area or organ to be classified as an MBE it had to be associated with a symptomatic clinical presentation.
Bleeding causing a fall in haemoglobin level of 20 g/L (1.24 mmol/L) or more, or leading to transfusion of 2 or more units of whole blood or red cells.
Table 15 shows bleeding events in pivotal study RE-MEDY testing prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE).
The definition of MBEs followed the recommendations of the International Society on Thrombosis and Haemostasis as described under RE-COVER and RE-COVER II.
Table 16 shows bleeding events in pivotal study RE-SONATE testing prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE). The rate of the combination of MBEs/ CRBEs and the rate of any bleeding was significantly lower at a nominal alpha level of 5% in patients receiving placebo as compared with those receiving dabigatran etexilate.
The definition of MBEs followed the recommendations of the International Society on Thrombosis and Haemostasis as described under RE-COVER and RE-COVER II.

Liver function tests.

There were no important differences in median ALT, AST, total bilirubin, and alkaline phosphatase (ALP) values in the dabigatran etexilate group compared with the warfarin or placebo groups (see Tables 17 and 18).

Myocardial infarction.

In the three active controlled studies, a higher rate of MI was reported in patients who received dabigatran etexilate than in those who received warfarin: 0.4% vs. 0.2% in the short-term RECOVER and RECOVER II studies; and 0.8% vs. 0.1% in the long-term RE-MEDY trial. The increase was statistically significant in this study (p = 0.022).
In the RE-SONATE study, which compared dabigatran etexilate to placebo, the rate of MI was 0.1% for patients who received dabigatran etexilate and 0.2% for patients who received placebo (see Section 4.4 Special Warnings and Precautions for Use).

Overview of adverse events from RE-COVER and RE-COVER II.

In well controlled clinical trials the incidences of adverse events of Pradaxa vs. warfarin were: RE-COVER 66 vs. 68%, RE-COVER II 67 vs. 71%. Adverse events classified by SOC and preferred terms reported ≥ 2% from any treatment group of the RE-COVER trials are shown in Table 19.
The overall frequency of adverse reactions in patients receiving Pradaxa for acute DVT/PE treatment was lower for Pradaxa compared to warfarin (14.2% vs. 18.9%).
Adverse reactions (< 2%) observed with exposure to dabigatran 150 mg twice daily during the RE-COVER trials are listed below by system organ class and frequency according to the following categories: common ≥ 1% and < 10%, uncommon ≥ 0.1% and < 1%, rare ≥ 0.01% and < 0.1%.

Blood and lymphatic system disorders.

Uncommon: anaemia.
Rare: thrombocytopenia.

Immune system disorders.

Uncommon: drug hypersensitivity (including drug hypersensitivity, pruritus, rash, urticaria, bronchospasm).
Rare: angioedema.

Nervous system disorders.

Rare: intracranial haemorrhage.

Vascular disorders.

Uncommon: haematoma, haemorrhage.

Respiratory, thoracic and mediastinal disorders.

Uncommon: haemoptysis.

Gastrointestinal disorders.

Common: gastrointestinal haemorrhage.
Uncommon: abdominal pain, gastrointestinal ulcer, gastrooesophagitis, gastrooesophageal reflux disease.
Rare: dysphagia.

Hepatobiliary disorders.

Uncommon: hepatic function abnormal.

Skin and subcutaneous tissue disorders.

Common: skin haemorrhage.

Musculoskeletal and connective tissue disorders.

Uncommon: haemarthrosis.

Renal and urinary disorders.

Common: urogenital haemorrhage.

General disorders and administration site conditions.

Rare: injection site haemorrhage, catheter site haemorrhage.

Injury, poisoning and procedural complications.

Uncommon: traumatic haemorrhage.
Rare: incision site haemorrhage.

Overview of adverse events from RE-MEDY and RE-SONATE.

In well controlled clinical trials the incidences of adverse events of Pradaxa vs. warfarin were: RE-SONATE 51 vs. 49%, RE-MEDY 72 vs. 71%. Adverse events classified by SOC and preferred terms reported ≥ 2% from any treatment group of the RE-MEDY and RE-SONATE trials are shown in Table 20.
The overall frequency of adverse reactions in patients treated for recurrent DVT/PE prevention was lower for Pradaxa compared to warfarin (14.6% vs. 19.6%); compared to placebo the frequency was higher (14.6% vs. 6.5%).
Adverse reactions (< 2%) observed with exposure to dabigatran 150 mg twice daily during the RE-MEDY and RE-SONATE trials are listed below by system organ class and frequency according to the following categories: common ≥ 1% and < 10%, uncommon ≥ 0.1% and < 1%, rare ≥ 0.01% and < 0.1%.

Blood and lymphatic system disorders.

Rare: anaemia, thrombocytopenia.

Immune system disorders.

Uncommon: drug hypersensitivity (including drug hypersensitivity, pruritus, rash, urticaria, bronchospasm).
Rare: angioedema.

Nervous system disorders.

Rare: intracranial haemorrhage.

Vascular disorders.

Uncommon: haematoma, haemorrhage.

Respiratory, thoracic and mediastinal disorders.

Uncommon: haemoptysis.

Gastrointestinal disorders.

Common: gastrointestinal haemorrhage.
Uncommon: abdominal pain, gastrooesophagitis, gastrooesophageal reflux disease, vomiting.
Rare: dysphagia, gastrointestinal ulcer.

Hepatobiliary disorders.

Uncommon: hepatic function abnormal.

Skin and subcutaneous tissue disorders.

Common: skin haemorrhage.

Musculoskeletal and connective tissue disorders.

Rare: haemarthrosis.

Renal and urinary disorders.

Common: urogenital haemorrhage.

General disorders and administration site conditions.

Rare: injection site haemorrhage, catheter site haemorrhage.

Injury, poisoning and procedural complications.

Rare: traumatic haemorrhage, incision site haemorrhage.

Postmarketing surveillance.

In addition, the following events have been reported with the use of Pradaxa in clinical practice.

Blood and lymphatic system disorders.

Not known: neutropenia, agranulocytosis.

Immune system disorders.

Rare: angioedema, anaphylactic reactions.

Skin and subcutaneous tissue disorders.

Not known: alopecia.

4.2 Dose and Method of Administration

Pradaxa capsules can be taken with or without food. Pradaxa should be swallowed whole with a full glass of water, to facilitate delivery to the stomach.
The capsule should not be chewed, broken, or opened as this may increase the risk of bleeding (see Section 5.2 Pharmacokinetic Properties, Absorption).
In case of intolerability to dabigatran, patients should be instructed to immediately consult their treating physician in order to be switched to alternate acceptable treatment options.

Prevention of venous thromboembolism (VTE) following major orthopaedic surgery of the lower limb (elective total hip or knee replacement).

The recommended dose of Pradaxa is 220 mg taken orally as two 110 mg capsules once daily.
Patients with moderate renal impairment (30-50 mL/min CrCL) have an increased risk for bleeding. For those patients the recommended dose of Pradaxa is 150 mg given as two 75 mg capsules once daily.
Treatment of Pradaxa should be initiated orally within 1-4 hours of completed surgery with a single capsule (110 mg) and continuing with 2 capsules once daily thereafter for the required duration. If haemostasis is not secured, initiation of treatment should be delayed. If treatment is not started on the day of surgery then treatment should be initiated with 2 capsules once daily.

VTE prevention following knee replacement surgery.

Treatment for a total of 10 days.

VTE prevention following hip replacement surgery.

Treatment for a total of 28-35 days.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation.

The recommended daily dose of Pradaxa is 300 mg taken orally as one 150 mg capsule twice daily.
In patients with moderate renal impairment (30-50 mL/min CrCL) a reduced dose of 220 mg given as one 110 mg capsule twice daily may be considered.
Patients aged 75 years and above should be treated with a daily dose of 220 mg taken orally as one 110 mg capsule twice daily.
For patients with a potentially higher risk of major bleeding (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk, Table 3) a reduced dose of 220 mg given as 110 mg twice daily may be considered.
Treatment should be continued life-long.

Treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

The recommended daily dose of Pradaxa is 300 mg taken orally as one 150 mg capsule twice daily following treatment with a parenteral anticoagulant for at least 5 days. The duration of therapy should be individualised after careful assessment of the treatment benefit against the risk for bleeding. Short duration of therapy (at least 3 months) should be based on transient risk factors (e.g. recent surgery, trauma, immobilisation) and longer durations should be based on permanent risk factors or idiopathic DVT or PE.
In patients with moderate renal impairment (30-50 mL/min CrCL) a reduced dose of 220 mg given as one 110 mg capsule twice daily may be considered.
Patients aged 75 years and above should be treated with a daily dose of 220 mg taken orally as one 110 mg capsule twice daily.
For patients with a potentially higher risk of major bleeding (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk, Table 3) a reduced dose of 220 mg given as 110 mg twice daily may be considered. Limited clinical data are available for patients with multiple risk factors. In these patients, Pradaxa should only be given if the expected benefit outweighs bleeding risks.
For DVT/PE the recommendation for the use of Pradaxa 220 mg taken as one 110 mg capsule twice daily is based on pharmacokinetic and pharmacodynamic analyses and has not been studied in this clinical setting for efficacy and safety.

Special patient populations.

Patients at risk of bleeding.

Patients with an increased bleeding risk (see Section 4.4 Special Warnings and Precautions for Use, Haemorrhagic risk, Table 3) should be closely monitored clinically (looking for signs of bleeding or anaemia). Dose adjustment should be decided at the discretion of the physician, following assessment of the potential benefit and risk to an individual patient (for dosage adjustment, see Section 4.2 Dose and Method of Administration, Prevention of venous thromboembolism (VTE) following major orthopaedic surgery of the lower limb (elective total hip or knee replacement), Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation, Treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults sections above). A coagulation test may help to identify patients with an increased bleeding risk caused by excessive dabigatran exposure. When clinically relevant bleeding occurs, treatment should be interrupted.

Hepatic impairment.

Patients with liver disease expected to have any impact on survival or with elevated liver enzymes > 2 ULN were excluded in clinical trials. Therefore the use of Pradaxa is not recommended in this population.

Renal impairment.

Renal function should be assessed by calculating the creatinine clearance (CrCL) prior to initiation of treatment with Pradaxa to exclude patients for treatment with severe renal impairment (i.e. CrCL < 30 mL/min). Treatment with Pradaxa in patients with severe renal impairment (CrCL < 30 mL/min) is not recommended (see Section 4.3 Contraindications). There are no data to support use in this population.
While on treatment renal function should be assessed in certain clinical situations when it is suspected that the renal function could decline or deteriorate (such as hypovolemia, dehydration, and with certain comedications).

Prevention of venous thromboembolism (VTE) following major orthopaedic surgery of the lower limb (elective total hip or knee replacement).

After i.v. application 85% of dabigatran in plasma is cleared through the kidneys. Patients with moderate renal impairment (CrCL 30-50 mL/min) appear to be at higher risk of bleeding. Dosing should be reduced to 150 mg Pradaxa taken once daily as 2 capsules of 75 mg in patients with moderate renal impairment.
Treatment with Pradaxa should be initiated orally within 1-4 hours of completed surgery with a single capsule of 75 mg and continuing with 2 capsules of 75 mg once daily thereafter for a total of 10 days (following knee replacement surgery) or 28-35 days (following hip replacement surgery).
For both surgeries, if haemostasis is not secured, initiation of treatment should be delayed. If treatment is not started on the day of surgery then treatment should be initiated with 2 capsules once daily.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

In patients with moderate renal impairment (CrCL 30-50 mL/min) a reduced dose of 220 mg given as one 110 mg capsule twice daily may be considered and renal function should be assessed at least once a year.
The method used to estimate renal function (CrCL in mL/min) during the clinical development of Pradaxa was the Cockcroft-Gault method. The formula is as follows.
This method is recommended when assessing patients' CrCL prior to and during dabigatran treatment.
The formula for estimated glomerular filtration rate (eGFR) from the Modification of Diet in Renal Disease (MDRD) study is as follows.
See Table 1.

Elderly.

Pharmacokinetic studies in older subjects demonstrate an increase in drug exposure in those patients with age related decline of renal function. As renal impairment may be frequent in the elderly (> 75 years), renal function should be assessed by calculating the creatinine clearance (CrCL) prior to initiation of treatment with Pradaxa to exclude patients for treatment with severe renal impairment (i.e. CrCL < 30 mL/min). The renal function should also be assessed at least once a year in patients treated with Pradaxa or more frequently as needed in certain clinical situations when it is suspected that the renal function could decline or deteriorate (such as hypovolemia, dehydration, and with certain comedications).
Also see Section 4.2 Dose and Method of Administration, Renal impairment above.

Prevention of venous thromboembolism (VTE) following major orthopaedic surgery of the lower limb (elective total hip or knee replacement).

No dose adjustment necessary, patients should be treated with 220 mg Pradaxa taken once daily as 2 capsules of 110 mg.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

Patients aged 75 years and above should be treated with a daily dose of 220 mg taken orally as one 110 mg capsule twice daily.

Weight.

No dose adjustment is necessary.

Post-surgical patients with an increased risk for bleeding.

Patients at risk for bleeding or patients at risk of overexposure, notably patients with moderate renal impairment (creatinine clearance 30-50 mL/min), should be treated with caution (see Section 4.4 Special Warnings and Precautions for Use; Section 5.1 Pharmacodynamic Properties).

Children and adolescents.

There is no experience in children and adolescents. Pradaxa is not recommended for use in patients below 18 years due to lack of data on safety and efficacy.

Concomitant use of Pradaxa with strong P-glycoprotein inhibitors e.g. amiodarone, quinidine or oral verapamil.

Simultaneous initiation of treatment with Pradaxa and oral verapamil should be avoided (see Section 4.3 Contraindications).

Prevention of venous thromboembolism (VTE) following major orthopaedic surgery of the lower limb (elective total hip or knee replacement).

Dosing should be reduced to Pradaxa 150 mg taken once daily as 2 capsules of 75 mg in patients who receive concomitant Pradaxa and amiodarone or quinidine (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
Dosing should be reduced to Pradaxa 150 mg taken once daily as 2 capsules of 75 mg and maintained on that dose when patients are commenced on Pradaxa whilst receiving existing oral verapamil treatment (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
Treatment initiation with oral verapamil should be avoided in patients following major orthopaedic surgery who are already treated with Pradaxa.
Treatment with Pradaxa should be initiated orally within 1-4 hours of completed surgery with a single capsule of 75 mg and continuing with 2 capsules of 75 mg once daily thereafter for a total of 10 days (following knee replacement surgery) or 28-35 days (following hip replacement surgery).
For both surgeries, if haemostasis is not secured, initiation of treatment should be delayed. If treatment is not started on the day of surgery then treatment should be initiated with 2 capsules once daily.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

P-gp inhibitors verapamil, amiodarone and quinidine do not require dose adjustments (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions), but co-administration of Pradaxa with strong P-gp inhibitors should be used with caution. Patients should be treated with a daily dose of 300 mg taken orally as a 150 mg capsule twice daily.
The effect of individual P-gp inhibitors vary and results should not be extrapolated to other P-gp inhibitors.
When verapamil needs to be initiated on stable dabigatran etexilate therapy or dabigatran etexilate and verapamil need to be initiated concurrently, dabigatran etexilate should be given at least 2 hours before verapamil for the first three days.
Concomitant treatment with systemic ketoconazole, ciclosporin, itraconazole, dronedarone or the fixed-dose combination glecaprevir/pibrentasvir is contraindicated.

Switching from Pradaxa treatment to parenteral anticoagulant.

Prevention of venous thromboembolism (VTE) following major orthopaedic surgery of the lower limb (elective total hip or knee replacement).

Wait 24 hours after the last dose before switching from Pradaxa to a parenteral anticoagulant.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

Wait 12 hours after the last dose before switching from Pradaxa to a parenteral anticoagulant.

Switching from parenteral anticoagulants treatment to Pradaxa.

Pradaxa should be given 0-2 hours prior to the time that the next dose of the alternate therapy would be due, or at the time of discontinuation in case of continuous treatment (e.g. intravenous unfractionated heparins).

Switching from vitamin K antagonists to Pradaxa.

The vitamin K antagonist should be stopped. Pradaxa can be given as soon as the INR is < 2.0.

Switching from Pradaxa to warfarin.

When converting from Pradaxa to warfarin, adjust the starting time of warfarin based on creatinine clearance as follows.
For CrCL > 50 mL/min, start warfarin 3 days before discontinuing Pradaxa.
For CrCL 31-50 mL/min, start warfarin 2 days before discontinuing Pradaxa.
For CrCL 15-30 mL/min, start warfarin 1 day before discontinuing Pradaxa.
For CrCL < 15 mL/min, no recommendations can be made.
Because Pradaxa can contribute to an elevated INR, the INR will better reflect warfarin's effect after Pradaxa has been stopped for at least 2 days.

Cardioversion.

Patients can stay on Pradaxa while being cardioverted.

Percutaneous coronary intervention (PCI) with stenting (SPAF).

Patients with non-valvular atrial fibrillation who undergo a PCI with stenting can be treated with Pradaxa in combination with antiplatelets after haemostasis is achieved (see Section 5.1 Pharmacodynamic Properties, Clinical trials).

Catheter ablation for atrial fibrillation.

Catheter ablation can be conducted in non-valvular atrial fibrillation patients on 150 mg twice daily Pradaxa treatment. Pradaxa treatment does not need to be interrupted. There are no clinical data on continuation of Pradaxa treatment during catheter ablation in those non-valvular atrial fibrillation patients receiving 110 mg twice daily (see Section 5.1 Pharmacodynamic Properties, Clinical trials).

Missed dose.

Prevention of venous thromboembolic events in adult patients who have undergone major orthopaedic surgery.

The patient should continue with their remaining daily doses of Pradaxa at the same time the next day. Do not take a double dose to make up for missed individual doses.

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and treatment of, and prevention of recurrent, deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in adults.

A missed Pradaxa dose may still be taken up to 6 hours prior to the next scheduled dose. From 6 hours prior to the next scheduled dose on, the missed dose should be omitted. Do not take a double dose to make up for missed individual doses.

Instruction for use/ handling.

When removing a hard capsule from the blister, please note the following instructions:
Tear off one individual blister from the blister card along the perforated line.
Peel off the backing foil and remove the capsule.
The capsule should not be pushed through the blister foil.
Any unused product or waste material should be disposed in accordance with local requirements.

4.7 Effects on Ability to Drive and Use Machines

No studies on the effects on the ability to drive and use machines have been performed.

4.9 Overdose

For information on the management of overdose contact the Poisons Information Centre on 13 11 26 (Australia).
Overdose following administration of dabigatran etexilate may lead to haemorrhagic complications due to its pharmacodynamic properties. Coagulation tests can help to determine a potential bleeding risk in this setting.
Doses of dabigatran etexilate beyond those recommended expose the patient to increased risk of bleeding. Excessive anticoagulation may require discontinuation of dabigatran etexilate. In the event of haemorrhagic complications, treatment must be discontinued and the source of bleeding investigated. Since dabigatran is excreted predominantly by the renal route adequate diuresis must be maintained. Depending on the clinical situation, appropriate standard treatment including patient monitoring, resuscitation and haemostasis is essential. Management should be guided by local protocols.
For situations of life-threatening or uncontrolled bleeding, or in cases of emergency surgery or urgent procedures when rapid reversal of the anticoagulation effects of dabigatran is required, the specific reversal agent Praxbind (idarucizumab) is available (see Section 4.4 Special Warnings and Precautions for Use, Surgery and interventions, Preoperative phase).
As protein binding is low dabigatran is dialysable, however there is limited clinical experience in using dialysis in this setting (see Section 5.2 Pharmacokinetic Properties, Special populations, Renal impairment).
In cases of severe bleeding, prothrombin factor complexes may be considered. There is some experimental evidence to support the role of activated prothrombin complex concentrates and recombinant factor VIIa in reversing the anticoagulant effect of dabigatran but their usefulness in clinical settings has not yet been systematically demonstrated and their use may cause an excessive risk of thrombosis when the effects of dabigatran have waned. Consideration should also be given to administration of platelet concentrates in cases where thrombocytopenia is present or long acting antiplatelet drugs have been used. All symptomatic treatment has to be given according to the physician's judgement.

7 Medicine Schedule (Poisons Standard)

S4.

6 Pharmaceutical Particulars

6.1 List of Excipients

Capsule fill: Tartaric acid, acacia, hypromellose, dimeticone 350, purified talc, hyprolose.
HPMC capsule shell: Carrageenan, potassium chloride, titanium dioxide, indigo carmine CI73015 (110 mg and 150 mg capsules only), hypromellose, purified water.
Printing ink: TekPrint SW-9008 black ink.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 30°C. Protect from moisture.
Do not put the capsules in pill boxes or pill organisers, unless capsules can be maintained in the original package.

6.5 Nature and Contents of Container

Capsules 75 mg: PA/Al/PVC/Al blister packs: 10, 30*, 60 capsules.
Capsules 110 mg: PA/Al/PVC/Al blister packs: 10, 30*, 60 capsules.
Capsules 150 mg: PA/Al/PVC/Al blister packs: 10 (sample), 60 capsules.
*Not distributed in Australia.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

Summary Table of Changes