What is the recommended management of anticoagulation (Anti-Coagulation) therapy, including warfarin and direct oral anticoagulants (DOACs) such as rivaroxaban (Xarelto) and apixaban (Eliquis), in patients requiring surgery?

Perioperative Management of Anticoagulation Therapy

For patients requiring surgery, anticoagulation therapy should be interrupted based on the bleeding risk of the procedure and the patient's thrombotic risk, with warfarin stopped 3-5 days before surgery and direct oral anticoagulants (DOACs) stopped 1-5 days before surgery depending on the specific agent and the patient's renal function. 1

Preoperative Management

Risk Stratification

• Procedures should be classified by bleeding risk: minimal, low-to-moderate, or high risk 1, 2
• Patient thrombotic risk should be assessed to determine if bridging therapy is necessary 1

Warfarin Management

• Stop warfarin 3-5 days before high-risk surgical procedures 1
• Target INR should be less than 1.5 before proceeding with surgery 1
• For patients at high thrombotic risk (mechanical heart valves, recent stroke, recent venous thromboembolism), bridging with heparin may be required 1, 3

DOAC Management

• For low-to-moderate bleeding risk procedures:

  • Stop DOACs 1 day before surgery (skip 1-2 doses) 1, 2
  • For dabigatran, interruption time depends on renal function 1

• For high bleeding risk procedures:

  • Stop rivaroxaban, apixaban, and edoxaban 3 days before surgery 1
  • Stop dabigatran 4 days before surgery if CrCl >50 mL/min and 5 days before surgery if CrCl is 30-50 mL/min 1

• For very high bleeding risk procedures (e.g., neuraxial anesthesia, neurosurgery):

  • Longer interruption times up to 5 days may be needed 1, 4

• No preoperative heparin bridging is typically needed for DOACs except in patients at very high thrombotic risk 1

Postoperative Management

Warfarin Resumption

• Restart warfarin 12-24 hours after surgery if bleeding risk is acceptable 1
• For patients requiring bridging, delay resumption of therapeutic-dose heparin for 48-72 hours after major surgery 1

DOAC Resumption

• For minimal bleeding risk procedures:

  • DOACs can be resumed the same day (at least 6 hours after procedure) 1

• For low-to-moderate bleeding risk procedures:

  • Resume DOACs 1 day after surgery 1, 2

• For high bleeding risk procedures:

  • Resume DOACs 2-3 days after surgery 1
  • Consider reduced doses initially (e.g., rivaroxaban 10 mg once daily for 2 days before increasing to 20 mg) 1
  • For dabigatran, consider 75-150 mg once daily for the first 1-2 days before resuming full dose 1

• If immediate postoperative thromboprophylaxis is needed, administer heparin or fondaparinux at least 6 hours after the procedure, then transition to DOAC therapy when appropriate 1

Special Considerations

Minor Procedures

• For dental, dermatologic, and ophthalmologic procedures, warfarin can often be continued within the therapeutic INR range 1
• Similarly, DOACs can often be continued for minimal bleeding risk procedures 1, 2

Neuraxial Anesthesia

• Longer interruption of anticoagulants is required before neuraxial anesthesia to prevent spinal/epidural hematoma 1, 5
• The entire interruption protocol must be completed before neuraxial procedures, particularly for patients on dabigatran with renal impairment or advanced age 1

Common Pitfalls to Avoid

• Failing to assess both thrombotic and bleeding risks before deciding on perioperative anticoagulation strategy 1
• Inappropriate bridging therapy in low-risk patients, which increases bleeding risk without benefit 1
• Resuming full-dose anticoagulation too soon after high bleeding risk procedures 1
• Inadequate interruption time for patients with renal impairment, particularly those on dabigatran 1
• Continuing warfarin in patients undergoing procedures with high bleeding risk, such as TURP or percutaneous nephrolithotomy 1, 6
• Overlapping anticoagulants when transitioning between agents 4