What is the recommended management of anticoagulants (blood thinners), such as warfarin or direct oral anticoagulants (DOACs) like apixaban (eliquis) or rivaroxaban (xarelto), before surgery?

Management of Anticoagulants Before Surgery

For patients on anticoagulants requiring surgery, discontinuation timing should be based on the bleeding risk of the procedure, the type of anticoagulant, and patient-specific factors such as renal function. 1

Direct Oral Anticoagulants (DOACs)

Low Bleeding Risk Procedures

• DOACs should be interrupted the night before the procedure regardless of the specific DOAC type 1
• For twice daily regimens, the last dose should be taken on the morning of the day before surgery 1
• For once daily morning regimens, the last dose should be on the morning of the day before surgery 1
• For once daily evening regimens, the last dose should be two days before surgery 1
• Bridging with heparin is not recommended before procedures with low bleeding risk 1

High Bleeding Risk Procedures

• For rivaroxaban, apixaban, and edoxaban: discontinue 3 days before the procedure 1
• For dabigatran: discontinue based on renal function 1:
  • 4 days before if creatinine clearance >50 mL/min
  • 5 days before if creatinine clearance 30-50 mL/min
• For apixaban specifically, FDA labeling recommends discontinuation at least 48 hours prior to elective surgery with moderate/high bleeding risk 2

Very High Bleeding Risk Procedures

• For intracranial neurosurgery or neuraxial anesthesia, longer interruption times are needed 1
• Up to 5 days for all DOACs in the absence of renal failure 1
• Neuraxial anesthesia should not be performed in patients with insufficient DOAC discontinuation time 1

Vitamin K Antagonists (Warfarin)

• Stop warfarin 3-5 days before surgery with daily INR monitoring until ≤1.5 is reached 1
• Start LMWH or UFH one day after discontinuation of warfarin or when INR <2.0 1
• For patients with mechanical heart valves, hospitalization and IV UFH until 4 hours before surgery is recommended 1
• Consider postponing the procedure if INR >1.5 on the day of surgery 1

Resumption of Anticoagulation

DOACs

• Resume DOACs at least 6 hours after the end of the procedure if adequate hemostasis is achieved 1
• For once daily evening regimen: resume the evening of the procedure day 1
• For once daily morning regimen: resume the next morning 1
• For twice daily regimen: resume the evening of the same day 1
• If there is ongoing bleeding or surgical contraindication, delay resumption and consider venous thromboprophylaxis 1

Warfarin

• Resume warfarin 1-2 days after surgery depending on hemostatic status 1
• Use the pre-operative maintenance dose plus a 50% boosting dose for two consecutive days 1
• Continue LMWH or UFH until the INR returns to therapeutic levels 1

Special Considerations

• No bridging with heparin is needed for DOACs except in very high thrombotic risk patients 1
• For procedures with minimal bleeding risk (e.g., minor dental or skin procedures), anticoagulants may be continued 3
• For emergency procedures, laboratory testing to measure DOAC levels may help determine if reversal agents are needed 3
• Recent evidence shows increased bleeding risk with bridging anticoagulation without reduction in thrombotic risk 1

Common Pitfalls to Avoid

• Failing to consider renal function when stopping dabigatran (which is 80% renally excreted) 1
• Unnecessary bridging with heparin for DOACs, which increases bleeding risk without benefit 1
• Inadequate discontinuation time before neuraxial anesthesia, which carries significant bleeding risks 1
• Not checking INR before procedures in patients on warfarin 1
• Resuming full-dose anticoagulation too early after surgery with high bleeding risk 1