In patients with atrial fibrillation, dabigatran given at a dose of 110 mg was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin, as well as lower rates of major hemorrhage. Dabigatran administered at a dose of 150 mg, as compared with warfarin, was associated with lower rates of stroke and systemic embolism but similar rates of major hemorrhage. (ClinicalTrials.gov number, NCT00262600.)

Idarucizumab completely reversed the anticoagulant effect of dabigatran within minutes. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947.).

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We agree with Drs Govindarajan and Salgado that because dabigatran 110 mg BID is associated with a lower risk of bleeding, it might be preferred over the 150-mg BID dose in patients with atrial fibrillation who are Ͼ75 years old and in clinical situations associated with a high risk of bleeding (eg, soon after thrombolysis or in the first few days after an invasive procedure). 1,2 Although not approved in the United States, the 110-mg BID dose of dabigatran is approved for use in Canada (where at least one third of patients are receiving it), Europe, and several other countries for patients at high risk of bleeding.Dr Reiffel requests additional information about the risks of bleeding with dabigatran compared with warfarin in atrial fibrillation patients with multiple factors that might increase the level of dabigatran in the blood. These analyses from the RE-LY database are under way but involve only small numbers of patients and are expected to provide imprecise estimates of treatment effect. We agree that it would be prudent to consider the 110-mg BID dose of dabigatran in preference to the 150-mg BID dose in these patients.We agree with Dr Rosenstein et al that an antidote for dabigatran has the potential to stop bleeding if the anticoagulant effect of the drug can be reversed rapidly. Despite the lack of an antidote, the RE-LY trial demonstrated that both doses of dabigatran (110 mg BID and 150 mg BID) were associated with lower rates of total, intracranial, and life-threatening bleeding than warfarin. 2 The mechanism of reduction in intracranial bleeding with both doses of dabigatran compared with warfarin has not been established but might simply be explained by avoidance of the high risk of intracranial bleeding with warfarin. Reasons for the high risk of intracranial bleeding with warfarin require further investigation. Concomitant use of a proton pump inhibitor might mitigate the increase in risk of gastrointestinal bleeding associated with dabigatran 150 mg BID. Avoidance of concomitant antiplatelet therapy might also reduce the risk.