From the Guidelines
Perioperative management of antithrombotic therapy should prioritize balancing the risks of thromboembolism against bleeding complications, with the most recent guidelines from 2024 suggesting specific interruption and resumption strategies for warfarin, direct oral anticoagulants (DOACs), and antiplatelet agents. The management strategy should be based on the type of antithrombotic therapy, the patient's renal function, the bleeding risk of the procedure, and the patient's thrombotic risk. For warfarin, discontinuation 5 days before surgery is recommended with INR check the day before procedure, aiming for INR <1.5, as suggested by 1 and further supported by 1. Bridge therapy with low molecular weight heparin may be needed for high-risk patients, as indicated in 1. DOACs, such as apixaban, rivaroxaban, and dabigatran, should be stopped 1-2 days before low bleeding risk procedures and 2-4 days before high bleeding risk procedures, with longer intervals for patients with renal impairment, as outlined in 1 and 1. Specifically, apixaban and rivaroxaban should be stopped 24-48 hours before low-risk procedures and 48-72 hours before high-risk procedures, while dabigatran requires 24-48 hours for low-risk and 48-96 hours for high-risk procedures depending on renal function, as detailed in 1. For antiplatelet therapy, aspirin can often be continued perioperatively except for neurosurgery, spinal procedures, or prostate surgery, as recommended by 1. Clopidogrel should be discontinued 5-7 days before surgery unless the patient has a recent coronary stent, with a suggested last intake five days before surgery for clopidogrel and ticagrelor, and seven days for prasugrel, as proposed by 1. For patients with recent stents, delaying elective surgery for at least 1 month after bare metal stent placement and 3-6 months after drug-eluting stent placement is optimal, as suggested by 1 and supported by 1. Resumption of anticoagulation typically occurs 24-72 hours after surgery based on hemostasis, with therapeutic doses of DOACs providing immediate anticoagulation while warfarin requires 5-10 days to reach therapeutic effect, as outlined in 1 and 1. This approach minimizes both thrombotic and hemorrhagic complications by considering individual patient factors including thrombotic risk, bleeding risk of the procedure, and medication pharmacokinetics, as emphasized by 1. Key considerations include:
- The type and dose of antithrombotic therapy
- Patient's renal function
- Bleeding risk of the procedure
- Patient's thrombotic risk
- Timing of interruption and resumption of antithrombotic therapy
- Use of bridge therapy when necessary
- Monitoring of INR and other coagulation parameters
- Collaboration with a multidisciplinary team to determine the best management strategy for each patient. The most recent guidelines from 2024, as outlined in 1, provide a comprehensive approach to perioperative management of antithrombotic therapy, emphasizing the importance of individualized patient care and multidisciplinary collaboration.
From the FDA Drug Label
2.3 Temporary Interruption for Surgery and Other Interventions Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5.2)]. Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled. Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.
The perioperative management of antithrombotic therapy with apixaban involves discontinuing the medication at least 48 hours before elective surgery or invasive procedures with a moderate or high risk of bleeding, and at least 24 hours before procedures with a low risk of bleeding.
- Bridging anticoagulation is not generally required during the 24 to 48 hours after stopping apixaban.
- Restarting apixaban should occur as soon as adequate hemostasis has been established after the surgical or other procedures 2.
For unfractionated heparin, the management involves adjusting the dosage according to the patient's coagulation test results, with a therapeutic anticoagulant effect typically achieved when the activated partial thromboplastin time (APTT) is 1.5 to 2 times the normal value 3.
- Converting to warfarin requires continuing full heparin therapy until the INR has reached a stable therapeutic range.
- Converting to oral anticoagulants other than warfarin involves stopping the intravenous heparin infusion immediately after administering the first dose of the oral anticoagulant.
From the Research
Perioperative Management of Antithrombotic Therapy
The perioperative management of antithrombotic therapy, including anticoagulation with medications like warfarin, direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, or dabigatran, and antiplatelet agents like aspirin or clopidogrel, is a complex process that requires careful consideration of the patient's risk for thromboembolism and bleeding [(4,5)].
Risk Stratification
Patients should be stratified according to their risk for thromboembolism and bleeding [(5,6)]. The risk of thromboembolism should be assessed based on the patient's medical history, including the presence of coronary artery disease, atrial fibrillation, or other conditions that increase the risk of thromboembolism [(4,7)]. The risk of bleeding should be assessed based on the type of surgical procedure, the patient's renal function, and other factors that may increase the risk of bleeding [(5,8)].
Management of Anticoagulation Therapy
The management of anticoagulation therapy during the perioperative period should be individualized based on the patient's risk for thromboembolism and bleeding [(4,5)]. In general, anticoagulation therapy should not be discontinued in patients with a high risk of thromboembolism, unless the risk of bleeding is also high [(4,8)]. In patients with a low risk of thromboembolism, anticoagulation therapy may be discontinued temporarily during the perioperative period [(5,6)].
Bridging Anticoagulation
Bridging anticoagulation with low-molecular-weight heparin or unfractionated heparin may be necessary in patients who require temporary interruption of warfarin therapy [(8,6)]. The indications and timing of bridging anticoagulation should be based on the patient's risk for thromboembolism and bleeding [(5,6)].
Antiplatelet Therapy
The management of antiplatelet therapy during the perioperative period should also be individualized based on the patient's risk for thromboembolism and bleeding [(4,5)]. In general, aspirin should not be stopped perioperatively in the majority of surgical operations 4. The use of other antiplatelet agents, such as clopidogrel, should be based on the patient's medical history and the type of surgical procedure [(5,7)].
- Key considerations for perioperative management of antithrombotic therapy:
- Risk stratification for thromboembolism and bleeding
- Individualized management of anticoagulation and antiplatelet therapy
- Use of bridging anticoagulation when necessary
- Consideration of the type of surgical procedure and the patient's medical history [(4,5,8,6,7)]