How is anticoagulation (use of medications to prevent blood clotting) managed in patients taking anticoagulants (such as warfarin, direct oral anticoagulants (DOACs) like rivaroxaban (Xarelto), apixaban (Eliquis), or dabigatran (Pradaxa)) prior to surgery?

Perioperative Management of Anticoagulants

Direct oral anticoagulants (DOACs) should be discontinued before elective surgery based on bleeding risk, with no need for heparin bridging in most cases, and resumed 24-72 hours postoperatively depending on the procedure's bleeding risk. 1, 2

Preoperative Management

Timing of Discontinuation Based on Bleeding Risk

Low Bleeding Risk Procedures

• DOACs can be continued or discontinued only on the day of procedure 2
• Examples: minor dental procedures, skin procedures, cataract surgery

Moderate Bleeding Risk Procedures

• Last DOAC dose timing:
  • Apixaban/Rivaroxaban/Edoxaban: Stop 2 days before procedure (skip 2 doses)
  • Dabigatran: Stop 3-4 days before procedure if CrCl >50 mL/min; 5 days if CrCl 30-50 mL/min 1

High Bleeding Risk Procedures

• Last DOAC dose timing:
  • Apixaban/Rivaroxaban/Edoxaban: Stop 3 days before procedure
  • Dabigatran: Stop 4 days before procedure if CrCl >50 mL/min; 5 days if CrCl 30-50 mL/min 1
  • For very high bleeding risk (intracranial neurosurgery, neuraxial anesthesia): Stop up to 5 days before procedure 1

Special Considerations

• Warfarin: Discontinue 5 days before procedure and check INR <3.0 before proceeding 3
• Renal function: Patients with impaired renal function require longer discontinuation periods, especially for dabigatran which has predominant renal elimination 1
• Age and drug interactions: Consider longer discontinuation for patients >80 years or those taking P-glycoprotein inhibitors or CYP3A4 inhibitors 1, 4

Bridging Anticoagulation

• No routine bridging needed for most patients on DOACs 2, 5
• Bridging with heparin significantly increases postoperative bleeding risk without reducing thrombotic events 6
• Consider bridging only for patients at very high thrombotic risk 1

Postoperative Management

Resumption of Anticoagulation

Timing Based on Bleeding Risk

• Low bleeding risk procedures: Resume DOACs 24 hours after procedure 4
• High bleeding risk procedures: Resume DOACs 48-72 hours after procedure 4, 2

Method of Resumption

• Resume full therapeutic dose when adequate hemostasis is established 4
• No need for overlapping with heparin when restarting DOACs 4
• For patients unable to take oral medications postoperatively, consider parenteral anticoagulation until oral intake is possible 3

Special Situations

Emergency Surgery

• For urgent/emergency surgery in patients on DOACs:
  • Consider laboratory testing to measure DOAC levels 2
  • For dabigatran: Idarucizumab can be safely administered 7
  • For factor Xa inhibitors (apixaban, rivaroxaban): Prothrombin complex concentrates may be considered 5, 7
  • Andexanet alfa should be avoided preoperatively for factor Xa inhibitors as it may induce temporary heparin resistance 7

Neuraxial Anesthesia

• Strongly avoid spinal/epidural anesthesia in patients with possible DOAC concentration (insufficient discontinuation time) 1
• Particularly important for patients on dabigatran who are >80 years or have renal failure 1

Monitoring and Safety

• No routine laboratory monitoring required for DOACs 5
• For emergency procedures, specific coagulation tests may help determine DOAC activity 2
• Monitor surgical site and vital signs regularly after resuming anticoagulation 4

Common Pitfalls to Avoid

1. Unnecessary bridging: Heparin bridging with DOACs increases bleeding risk without reducing thrombotic events 6
2. Inadequate discontinuation time: Failing to account for renal function when determining DOAC discontinuation timing 1
3. Premature resumption: Restarting anticoagulation before adequate hemostasis is established 4
4. Neuraxial anesthesia risks: Performing spinal/epidural procedures without adequate DOAC washout period 1
5. Overlooking drug interactions: Not accounting for medications that may increase DOAC plasma concentrations 1, 4

By following these guidelines, perioperative management of anticoagulants can be optimized to minimize both bleeding and thrombotic risks.