Timing of DOAC Discontinuation Before Surgery
For patients on direct oral anticoagulants (DOACs), discontinuation should occur 1 day before low bleeding risk procedures and 2 days before high bleeding risk procedures, with additional time needed for patients with impaired renal function. 1
DOAC Discontinuation Timeline by Bleeding Risk
Low Bleeding Risk Procedures:
- Apixaban: Hold for 1 day (CrCl >25 mL/min)
- Dabigatran: Hold for 1 day (CrCl >50 mL/min) or 2 days (CrCl 30-50 mL/min)
- Edoxaban: Hold for 1 day (CrCl >15 mL/min)
- Rivaroxaban: Hold for 1 day (CrCl >30 mL/min)
High Bleeding Risk Procedures:
- Apixaban: Hold for 2 days (CrCl >25 mL/min)
- Dabigatran: Hold for 2 days (CrCl >50 mL/min) or 4 days (CrCl 30-50 mL/min)
- Edoxaban: Hold for 2 days (CrCl >15 mL/min)
- Rivaroxaban: Hold for 2 days (CrCl >30 mL/min)
Special Considerations
Renal Function
- For patients with CrCl lower than the values in the table, consider holding for an additional 1-3 days, especially for high bleeding risk procedures 1
- For dabigatran (which has significant renal elimination):
- Hold for 4 days if CrCl >50 mL/min for high-risk procedures
- Hold for 5 days if CrCl is between 30-50 mL/min for high-risk procedures 1
Very High Bleeding Risk Procedures
For procedures with very high bleeding risk (e.g., intracranial neurosurgery or neuraxial anesthesia/puncture):
- Consider longer interruption times (up to 5 days) for all DOACs in the absence of renal failure 1
- Specific DOAC level testing may be considered if available, though not routinely required 2
Urgent/Emergent Procedures
For urgent procedures (within 24 hours):
- Consider laboratory testing to measure DOAC levels if time permits 3
- DOAC levels above 50 ng/mL may be considered clinically relevant and may necessitate reversal agents before urgent procedures 2
- In life-threatening situations, don't wait for DOAC level results before initiating reversal 2
Bridging Anticoagulation
- Preoperative bridging with heparin (UFH or LMWH) is not recommended when interrupting DOACs 1, 4
- No bridging therapy is needed unless the patient has very high thrombotic risk (e.g., recent history of pulmonary embolism or deep venous thrombosis) 4
DOAC Resumption After Surgery
For low bleeding risk procedures: Resume DOACs at least 6 hours after the procedure 1
- For once-daily evening regimen: Resume the evening of the procedure day
- For once-daily morning regimen: Resume the next morning
- For twice-daily regimen: Resume the evening of the same day
For high bleeding risk procedures: Delay resumption for 48-72 hours 4, 3
- Consider starting with prophylactic doses of LMWH 6-12 hours after surgery if hemostasis is adequate and there's concern about thrombotic risk 4
Common Pitfalls to Avoid
- Unnecessary bridging: Bridging with heparin is generally not needed and may increase bleeding risk without reducing thrombotic risk 1, 4
- One-size-fits-all approach: Failing to adjust timing based on renal function can lead to excessive anticoagulant effect during surgery
- Inadequate discontinuation time: Not allowing sufficient time for drug clearance before high bleeding risk procedures
- Premature resumption: Restarting DOACs too early after high bleeding risk procedures can increase bleeding complications
- Delayed resumption: Waiting too long to restart anticoagulation increases thrombotic risk
By following these evidence-based guidelines for DOAC management before surgery, you can minimize both bleeding and thrombotic complications in your patients.