Should Sulodexide (low molecular weight heparin) be continued or discontinued prior to orthopedic surgery?

Perioperative Management of Sulodexide for Orthopedic Surgery

Sulodexide should be discontinued 24 hours before orthopedic surgery, similar to the recommendation for therapeutic-dose low molecular weight heparin (LMWH), due to its anticoagulant properties and potential to increase bleeding risk. 1

Understanding Sulodexide's Pharmacological Profile

• Sulodexide is a glycosaminoglycan mixture composed of fast-moving heparin and dermatan sulfate that exerts anticoagulant and antithrombotic effects through interactions with antithrombin and heparin cofactor II 2
• It has antiplatelet effects and increases systemic fibrinolytic and thrombolytic activity, which can increase bleeding risk during surgical procedures 2, 3
• While sulodexide has better oral bioavailability and generally less bleeding risk than standard heparin, its anticoagulant properties still warrant perioperative management similar to other anticoagulants 2

Perioperative Management Recommendations

Timing of Discontinuation

• For orthopedic surgery, discontinue sulodexide approximately 24 hours before the procedure, following the same protocol as therapeutic-dose LMWH 1
• This timing allows for adequate clearance of the anticoagulant effect while minimizing the period without thromboprophylaxis 1

Resumption After Surgery

• Resume sulodexide 48-72 hours after high-bleeding-risk orthopedic procedures, once adequate hemostasis is achieved 1
• For procedures with lower bleeding risk, consider resuming sulodexide 24 hours postoperatively 1

Risk Assessment and Bridging Considerations

Thromboembolism Risk Stratification

• For patients at high risk for thromboembolism (recent VTE, mechanical heart valve), consider bridging anticoagulation during the perioperative period 1
• For patients at low risk for thromboembolism, no bridging is typically necessary during the brief interruption of sulodexide 1

Bleeding Risk Assessment

• Orthopedic procedures generally carry moderate to high bleeding risk, which supports the recommendation to discontinue sulodexide preoperatively 1, 4
• Combined use of sulodexide with other antiplatelet or anticoagulant medications significantly increases bleeding risk and may require longer discontinuation periods 5, 4

Special Considerations

• For minor procedures with minimal bleeding risk (dental, dermatologic, cataract surgery), continuing sulodexide may be considered if the thrombotic risk is significant 1, 5
• Patients with recent coronary stent placement require special consideration - if orthopedic surgery is elective, consider postponing until at least 6 weeks after bare-metal stent placement or 6 months after drug-eluting stent placement 1

Common Pitfalls and Caveats

• Failure to recognize sulodexide as an anticoagulant with similar perioperative management needs as LMWH 6, 2
• Inadequate communication between surgical and medical teams about the timing of sulodexide discontinuation 5, 4
• Not accounting for the potential increased bleeding risk when sulodexide is combined with other medications affecting hemostasis 5, 3
• Overlooking the need for individualized risk assessment balancing thrombotic and bleeding risks 1, 5

By following these evidence-based recommendations for perioperative management of sulodexide, clinicians can minimize both bleeding complications and thrombotic events in patients undergoing orthopedic surgery.