When to discontinue Coumadin (warfarin) or Pradaxa (dabigatran) prior to surgery?

From the Guidelines

For preoperative management, Coumadin (warfarin) should be stopped 5 days before surgery, while Pradaxa (dabigatran) should be discontinued 1 day before low-to-moderate-bleed-risk surgery or 2 days before high-bleed-risk surgery for patients with normal renal function (CrCl ≥ 50 mL/min), or 2 days before low-to-moderate-bleed-risk surgery or 4 days before high-bleed-risk surgery for those with impaired renal function (CrCl < 50 mL/min) 1. This timing allows the anticoagulant effect to diminish sufficiently to reduce bleeding risk during surgery. For Coumadin, the INR should be checked the day before surgery and should be below 1.5 for most procedures. Bridging therapy with low molecular weight heparin may be necessary for patients at high risk of thromboembolism, starting 3 days after stopping Coumadin and continuing until 24 hours before surgery. For Pradaxa, no bridging is typically required due to its shorter half-life. The decision to stop these medications should always be made in consultation with the prescribing physician and surgeon, balancing the risk of bleeding against the risk of thromboembolism. Some key points to consider when stopping these medications include:

• The type of surgery or procedure being performed, with high-bleed-risk procedures requiring longer durations of anticoagulant interruption 1
• The patient's renal function, with impaired renal function requiring longer durations of anticoagulant interruption 1
• The patient's risk of thromboembolism, with high-risk patients potentially requiring bridging therapy 1 Resumption of anticoagulation typically occurs 24-72 hours after surgery, depending on the bleeding risk of the procedure and the patient's thrombotic risk. It is essential to consider the most recent and highest quality study, which in this case is the 2022 American College of Chest Physicians clinical practice guideline 1.

From the FDA Drug Label

If possible, discontinue dabigatran etexilate capsules in adults 1 to 2 days (CrCl ≥50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before invasive or surgical procedures because of the increased risk of bleeding Consider longer times for patients undergoing major surgery, spinal puncture, or placement of a spinal or epidural catheter or port, in whom complete hemostasis may be required When converting patients from warfarin therapy to dabigatran etexilate capsules, discontinue warfarin and start dabigatran etexilate capsules when the INR is below 2. 0.

Discontinuation of Coumadin (warfarin) or Pradaxa (dabigatran) prior to surgery:

• For Pradaxa (dabigatran): discontinue 1 to 2 days before surgery if CrCl ≥50 mL/min, or 3 to 5 days before surgery if CrCl <50 mL/min.
• For Coumadin (warfarin): discontinue and start Pradaxa when INR is below 2.0. It is recommended to consider longer times for patients undergoing major surgery, spinal puncture, or placement of a spinal or epidural catheter or port, in whom complete hemostasis may be required 2.

From the Research

Discontinuation of Coumadin (Warfarin) Prior to Surgery

• According to 3, surgery can be conducted with minimal increased risk of bleeding if INR ≤ 1.5.
• Warfarin can be withheld for 5 days before surgery, or intravenous vitamin K₁ can be given the night before surgery 3.
• For patients with elevated INR (4.5-10.0), no bleeding and no high risk of bleeding, withholding warfarin with careful subsequent monitoring seems safe 3.
• The American College of Chest Physicians recommends stopping warfarin therapy five days before major surgery and restarting 12 to 24 hours postoperatively 4.

Discontinuation of Pradaxa (Dabigatran) Prior to Surgery

• There is no direct evidence provided for the discontinuation of Pradaxa (dabigatran) prior to surgery.
• However, 4 mentions that dabigatran is indicated for the prevention of systemic embolism and stroke in persons with nonvalvular atrial fibrillation, but does not provide specific guidance on discontinuation prior to surgery.

General Guidance for Anticoagulation Therapy

• Perioperative management of anticoagulant therapy requires an evaluation of the risk of thrombosis if warfarin is temporarily stopped, relative to the risk of bleeding if it is continued or modified 3.
• The risk of bleeding with warfarin use includes increasing age, history of bleeding, and specific comorbidities 3.
• Bridge therapy with low-molecular-weight heparin or other agents is based on balancing the risk of thromboembolism with the risk of bleeding 5, 4.

Reversal of Warfarin Anticoagulation

• Intravenous vitamin K1 should be used for procedures that can be delayed for six to 12 hr 6.
• If surgery cannot be delayed, prothrombin complex concentrates (PCCs) should be given, and intravenous vitamin K1 should be infused concurrently to ensure sustained reversal of anticoagulation 6.
• Prothrombin complex concentrates contain small amounts of heparin and are contraindicated in patients with heparin-induced thrombocytopenia 6.