Why is bridging not typically recommended for patients on Direct Oral Anticoagulants (DOACs)?

Why Bridging Is Not Recommended for Patients on Direct Oral Anticoagulants (DOACs)

Bridging anticoagulation is not recommended for patients on DOACs due to their rapid offset and onset of action, which eliminates the need for heparin bridging while significantly increasing bleeding risk without providing additional thromboembolic protection. 1

Pharmacological Rationale

DOACs have fundamentally different pharmacokinetic properties compared to warfarin:

• Rapid onset of action: Peak effect occurs 1-3 hours after intake 1
• Short half-lives: Allow for simple interruption and resumption 2
• Predictable anticoagulant effect: Unlike warfarin, which requires 5-7 days to reach therapeutic levels

These properties make the traditional concept of "bridging" unnecessary for DOACs.

Evidence Against DOAC Bridging

Multiple studies demonstrate increased harm with no benefit when bridging DOACs:

• In the RE-LY trial subanalysis, patients receiving LMWH bridging had significantly higher major bleeding rates (6.5% vs 1.8%, p<0.001) with no significant difference in stroke/systemic embolism (0.5% vs 0.3%, p=0.46) 1

• A prospective registry of 901 DOAC patients showed bridging was associated with:

  • Increased major bleeding risk (OR=4.6; 95% CI: 1.1-9.9)
  • No significant effect on thromboembolic outcomes (OR=1.9; 95% CI: 0.7-5.4) 1

• Meta-analysis data revealed a threefold higher incidence of major bleeding with bridging (4.8% vs 1.6%) and no difference in thromboembolic events 1

Proper DOAC Management for Procedures

Pre-Procedure Interruption

Timing depends on bleeding risk and specific DOAC:

• Low-to-moderate bleeding risk procedures:

  • Apixaban, edoxaban, rivaroxaban: Stop 1 day before
  • Dabigatran with CrCl ≥50 mL/min: Stop 1 day before
  • Dabigatran with CrCl <50 mL/min: Stop 2 days before 1

• High bleeding risk procedures:

  • Apixaban, edoxaban, rivaroxaban: Stop 2 days before
  • Dabigatran with CrCl ≥50 mL/min: Stop 2 days before
  • Dabigatran with CrCl <50 mL/min: Stop 4 days before 1

Post-Procedure Resumption

Timing depends on bleeding risk:

• Low-to-moderate bleeding risk: Resume ≥24 hours after procedure
• High bleeding risk: Resume 48-72 hours after procedure 1

Special Considerations

• Renal function: Monitor creatinine clearance postoperatively as it affects DOAC dosing and elimination 1

• Very high thrombotic risk: The French Working Group on Perioperative Hemostasis (GIHP) notes that bridging might be considered only in "very thrombotic high-risk" cases, but this is an exception rather than the rule 1

• Early phase VTE: For procedures during early phase of deep venous thrombosis or pulmonary embolism requiring high-dose anticoagulation, a personalized approach should be discussed by a multidisciplinary team 1

Common Pitfalls to Avoid

1. Automatic bridging habits: Clinicians familiar with warfarin management may reflexively bridge DOACs due to established practice patterns

2. Overestimating thrombotic risk: The short interruption period for DOACs (typically 24-48 hours) poses minimal thrombotic risk for most patients

3. Underestimating bleeding risk: Adding LMWH bridging significantly increases bleeding complications

4. Impaired renal function: Particular caution is needed in patients with kidney disease due to risk of accumulation and prolonged anticoagulant effect of both DOACs and LMWH 3

5. Unnecessary laboratory testing: Unlike warfarin, routine laboratory monitoring before procedures is not required for DOACs 4

In conclusion, the current evidence and guidelines strongly support a strategy of simple interruption and resumption of DOACs without bridging for most patients undergoing procedures, as this approach provides the optimal balance between thrombotic and bleeding risks.