How long should blood thinners, such as warfarin (anticoagulant), apixaban (Factor Xa inhibitor), and aspirin (acetylsalicylic acid), be held before a procedure to minimize bleeding risk?

Perioperative Management of Blood Thinners for Procedures

Blood thinners should be held before procedures based on bleeding risk, with DOACs discontinued 1 day before low-risk procedures and 2-3 days before high-risk procedures, while warfarin should be discontinued 3-5 days before high-risk procedures to minimize bleeding risk. 1

Timing of Discontinuation by Medication Type

Direct Oral Anticoagulants (DOACs)

For Low-to-Moderate Bleeding Risk Procedures:

• Hold for 1 day (24-36 hours) before procedure 1
  • For twice-daily regimens: Last dose on morning of day before procedure
  • For once-daily morning regimens: Last dose on morning of day before procedure
  • For once-daily evening regimens: Last dose two days before procedure

For High Bleeding Risk Procedures:

• Apixaban, Rivaroxaban, Edoxaban: Hold for 3 days before procedure 1
• Dabigatran: Hold based on renal function 1
  • CrCl >50 mL/min: Hold for 4 days
  • CrCl 30-50 mL/min: Hold for 5 days
  • CrCl <30 mL/min: Consider longer holding periods

For Very High Bleeding Risk Procedures (neurosurgery, neuraxial anesthesia):

• Consider longer interruption times 1

Warfarin

• Hold for 3-5 days before high-risk surgical procedures 1
• Target INR ≤1.4 for high-risk procedures and ≤2.0 for low-risk procedures 2

Aspirin and Antiplatelet Agents

• Low-dose aspirin: May be continued for low-risk procedures 1
• Discontinue before high-risk procedures and procedures with significant bleeding risk 1
• Clopidogrel, ticlopidine, prasugrel: Consider discontinuation based on thrombotic vs. bleeding risk 2

Special Considerations

Renal Function

• Dabigatran: Requires longer holding periods with impaired renal function (CrCl <50 mL/min) 1
• For severely impaired renal function (CrCl <30 mL/min), consider longer holding periods for all DOACs 1

Drug Interactions

• Patients taking medications that interfere with DOAC clearance (CYP3A4 or P-glycoprotein inhibitors) may require longer holding periods 1

Urgent Procedures

• For urgent procedures (within 24 hours), consider measuring DOAC levels 1
• Standard coagulation tests (INR, aPTT) may be insensitive; specific tests may be needed:
  • DOAC-calibrated anti-factor Xa levels for apixaban, edoxaban, and rivaroxaban
  • Dilute thrombin time or ecarin clotting time for dabigatran

Resumption of Anticoagulation

• DOACs: Resume at least 6 hours after procedure if hemostasis is adequate 1
  • Evening dose if once-daily evening regimen
  • Next morning if once-daily morning regimen
  • Evening of same day if twice-daily regimen
• Warfarin: Resume 12-24 hours postoperatively if bleeding risk is acceptable 1

Bridging Considerations

• Preoperative bridging with heparin is generally not recommended for DOACs 1
• For warfarin, bridging should be considered only in selected high-risk patients 2

Common Pitfalls to Avoid

1. Unnecessary bridging: Bridging increases bleeding risk without reducing thrombotic risk in most patients 1
2. One-size-fits-all approach: Failing to adjust holding times based on renal function, especially for dabigatran
3. Inadequate holding time for very high-risk procedures: Neuraxial anesthesia and intracranial procedures require longer holding periods
4. Resuming anticoagulation too early: Wait at least 6 hours after procedure and ensure adequate hemostasis
5. Overlooking drug interactions: Medications affecting DOAC metabolism may require longer holding periods

By following these guidelines, clinicians can minimize bleeding risk while managing the thrombotic risk associated with temporary interruption of anticoagulation for procedures.