Dabigatran etexilate is an oral direct thrombin inhibitor that has been approved by the US Food and Drug Administration for the prevention of stroke and systemic embolization in patients with nonvalvular atrial fibrillation. It has also been studied for the prevention of venous thromboembolism in patients after hip and knee arthroplasty and for treatment of venous thromboembolism. Although routine laboratory monitoring is not needed, there are clinical scenarios in which physicians will need to have a clear understanding of drug pharmacology, laboratory assessment, and reversibility of this drug to make appropriate clinical decisions. We review the pharmacology of dabigatran etexilate, pertinent clinical trials, and the effects of dabigatran etexilate on prothrombin time, activated partial thromboplastin time, thrombin time, and ecarin clotting time. We also provide an approach to patients on dabigatran etexilate who are bleeding, have a suspected therapeutic failure, or require periprocedural management.