What are the alternative strategies for heparin management during Direct Oral Anticoagulant (DOAC) washout?

Alternative Strategies for Heparin Management During DOAC Washout

Preoperative bridging with heparin is not recommended during DOAC washout periods for most patients, as it increases bleeding risk without providing additional thromboembolic protection. 1

DOAC Interruption Strategy Without Bridging

The French Working Group on Perioperative Hemostasis (GIHP) guidelines provide clear recommendations for managing DOAC interruption before procedures:

For Low Hemorrhagic Risk Procedures:

• Twice daily regimen: Last DOAC dose on morning of day before procedure
• Once daily morning regimen: Last dose on morning of day before procedure
• Once daily evening regimen: Last dose two days before procedure

For High Hemorrhagic Risk Procedures:

• Xaban drugs (rivaroxaban, apixaban, edoxaban): Last intake three days before procedure when creatinine clearance >30 mL/min
• Dabigatran:
  • Last intake four days before procedure if CrCl >50 mL/min
  • Last intake five days before procedure if CrCl 30-50 mL/min

When Bridging Should Be Considered

While routine bridging is not recommended, certain clinical scenarios may warrant consideration of alternative heparin management strategies:

1. Very high thrombotic risk patients: Those with recent (<3 months) VTE or mechanical heart valves
2. Prolonged DOAC interruption: When DOAC must be held for >72 hours
3. Procedures requiring neuraxial anesthesia: When longer DOAC-free periods are necessary

Heparin Bridging Options When Indicated

When bridging is deemed necessary, options include:

Low Molecular Weight Heparin (LMWH):

• Most commonly used bridging agent
• Therapeutic dosing (e.g., enoxaparin 1 mg/kg twice daily)
• Intermediate dosing (e.g., enoxaparin 40 mg twice daily) for patients with moderate thrombotic risk

Unfractionated Heparin (UFH):

• Option for patients with severe renal insufficiency (CrCl <30 mL/min) or dialysis-dependent
• Initial dose: 5,000 units IV bolus
• Maintenance: 20,000-40,000 units/24 hours continuous infusion 2
• Target aPTT 1.5-2.5 times control

Special Considerations

For Patients on DOACs Requiring Urgent Procedures:

• For FXa inhibitors (apixaban, rivaroxaban, edoxaban) with levels >50 ng/mL before urgent procedures, consider hemostatic intervention 3
• For dabigatran, idarucizumab can be used for reversal in emergency situations

For Patients with Heparin-Induced Thrombocytopenia (HIT):

• DOACs (particularly rivaroxaban) have shown efficacy in treating HIT with low thrombosis rates (2.2%) 4
• Consider direct transition to DOAC therapy rather than using heparin bridging

Weight-Based Heparin Dosing After DOAC Interruption:

• Patients previously on DOACs may require higher initial heparin doses (≥150 units/kg) to achieve therapeutic anticoagulation 5

DOAC Resumption After Procedure

In the absence of bleeding or surgical contraindication, DOAC treatment can resume at least six hours after the procedure:

• Evening of procedure day if once daily evening regimen
• Next morning if once daily morning regimen
• Evening of same day if twice daily regimen 1

Important Caveats

• Avoid bridging when possible: Evidence shows increased bleeding risk with heparin bridging without reduction in thromboembolic events 1
• Laboratory monitoring: When using heparin bridging, appropriate monitoring with aPTT or anti-Xa levels is essential
• Renal function: Always assess renal function before determining DOAC interruption timing and potential bridging strategy
• Timing is critical: When transitioning from heparin to DOAC, stop infusion and start DOAC at the same time to avoid anticoagulant overlap 6

By following these evidence-based strategies, clinicians can optimize the management of anticoagulation during DOAC washout periods while minimizing both bleeding and thrombotic risks.