What is the recommended approach for bridging anticoagulation in patients on Direct Oral Anticoagulants (DOACs) who require a procedure?

Management of Bridging Anticoagulation in Patients on DOACs

Bridging anticoagulation is not recommended for patients on Direct Oral Anticoagulants (DOACs) who require procedures, as DOACs have short half-lives that allow for simple interruption and resumption without the need for parenteral anticoagulation. 1, 2, 3

Interruption Protocol for DOACs Based on Bleeding Risk

Low Bleeding Risk Procedures

• Timing of Last Dose Before Procedure:
  • For twice daily regimen: Last dose on morning of day before procedure
  • For once daily morning regimen: Last dose on morning of day before procedure
  • For once daily evening regimen: Last dose two days before procedure 1

High Bleeding Risk Procedures

• For Factor Xa Inhibitors (Rivaroxaban, Apixaban, Edoxaban):

  • Interrupt 3 days before procedure if CrCl ≥30 mL/min 1
  • For transfemoral PCI: Interrupt 48 hours if CrCl ≥30 mL/min; 72 hours if CrCl <29 mL/min 1
  • For transradial PCI: Interrupt 24 hours if CrCl ≥30 mL/min; 36 hours if CrCl 15-29 mL/min; 48 hours if CrCl <15 mL/min 1

• For Dabigatran:

  • Interrupt 4 days before if CrCl >50 mL/min
  • Interrupt 5 days before if CrCl 30-50 mL/min 1
  • For transfemoral PCI: Timing varies by renal function from 48 hours (CrCl >80 mL/min) to 120 hours (CrCl 15-29 mL/min) 1
  • For transradial PCI: Timing varies by renal function from 24 hours (CrCl ≥80 mL/min) to 72 hours (CrCl 15-29 mL/min) 1

Very High Bleeding Risk Procedures (e.g., intracranial neurosurgery, neuraxial anesthesia)

• Consider longer interruption times than standard high bleeding risk procedures 1

Laboratory Testing

• Routine laboratory testing before procedures is not recommended for DOACs 1, 3
• For specific high-risk situations, agent-specific Factor Xa levels or diluted thrombin time may guide management 1

Resumption Protocol

Low Bleeding Risk Procedures

• Resume DOACs at least 6 hours after procedure completion 1, 2:
  • For once daily evening regimen: Resume the evening of procedure day
  • For once daily morning regimen: Resume the next morning
  • For twice daily regimen: Resume the evening of procedure day

High Bleeding Risk Procedures

• Delay DOAC resumption for 48-72 hours 2
• Consider prophylactic dose anticoagulation (e.g., LMWH) in the interim if thrombotic risk is high 1

Key Considerations

1. No Bridging Required: Unlike warfarin, DOACs do not require bridging with parenteral anticoagulants due to their predictable pharmacokinetics and short half-lives 1, 2, 3

2. Renal Function: Dabigatran requires longer interruption periods with declining renal function compared to factor Xa inhibitors 1

3. Vascular Access: Transradial access allows for shorter DOAC interruption times compared to transfemoral access 1

4. Procedure Urgency: For urgent/emergency procedures, consider radial approach without interrupting anticoagulation 1

5. Bleeding vs. Thrombotic Risk: The BRIDGE trial demonstrated that even for warfarin patients, bridging increased bleeding without reducing thromboembolism 4

Common Pitfalls to Avoid

1. Unnecessary Bridging: Using LMWH during DOAC interruption increases bleeding risk without providing additional thrombotic protection 1, 2, 3

2. Inadequate Interruption Time: Not accounting for renal function when determining DOAC interruption time, especially for dabigatran 1

3. Premature Resumption: Restarting DOACs too early after high bleeding risk procedures can lead to significant bleeding complications 2

4. Prolonged Interruption: Unnecessarily long DOAC interruption increases thrombotic risk; follow standardized protocols based on procedure bleeding risk 1, 2

5. One-Size-Fits-All Approach: Failing to adjust interruption timing based on specific DOAC, renal function, and procedure bleeding risk 1