What is the recommended bridging therapy for patients on dabigatran (Direct Oral Anticoagulant) who require temporary interruption for a procedure?

Bridging Therapy for Dabigatran

For patients on dabigatran requiring temporary interruption for procedures, bridging therapy is generally NOT recommended due to dabigatran's short half-life and predictable pharmacokinetics. 1

Timing of Dabigatran Interruption Before Procedures

The timing of dabigatran interruption depends on three key factors:

• Renal function: Dabigatran is primarily eliminated by the kidneys 1
• Bleeding risk of the procedure: Higher bleeding risk requires longer interruption 1
• Type of procedure/anesthesia: Procedures requiring complete hemostasis need longer interruption 2

Recommended Interruption Schedule:

For patients with normal or mildly impaired renal function (CrCl ≥50 mL/min):

• Low bleeding risk procedures: Last dose 2 days before surgery (skip 2 doses) 1
• High bleeding risk procedures: Last dose 3 days before surgery (skip 4 doses) 1

For patients with moderate renal impairment (CrCl 30-50 mL/min):

• Low bleeding risk procedures: Last dose 3 days before surgery (skip 4 doses) 1
• High bleeding risk procedures: Last dose 4-5 days before surgery (skip 6-8 doses) 1

No Need for Heparin Bridging

• The rapid offset and rapid onset of action of dabigatran obviate the need for heparin bridging with short-acting anticoagulants such as UFH or LMWH in the perioperative setting 1
• Evidence from clinical studies shows that bridging therapy with heparin in patients on DOACs is associated with increased bleeding risk without reduction in thromboembolic events 1
• In a subanalysis of the RE-LY trial, patients who received LMWH bridging had higher risk of major bleeding (6.5% vs 1.8%) with no significant effect on stroke/systemic embolism outcomes 1

Postoperative Resumption of Dabigatran

Timing of dabigatran resumption depends on the bleeding risk of the procedure:

• Low bleeding risk procedures: Resume dabigatran on the day after surgery (24 hours postoperative) at full dose (150 mg twice daily) 1
• High bleeding risk procedures: Resume dabigatran 2-3 days after surgery (48-72 hours postoperative) at full dose (150 mg twice daily) 1

For patients at high risk for thromboembolism undergoing high bleeding risk procedures:

• Consider administering a reduced dose of dabigatran (110-150 mg once daily) on the evening after surgery and on the first postoperative day 1

Special Considerations

• For minor procedures (dental, skin, cataract) where warfarin can be safely continued, it may be reasonable to continue dabigatran as well, though clinical data supporting this approach are limited 1
• If emergency surgery is required, use idarucizumab (specific reversal agent) to reverse the anticoagulant effect of dabigatran 2
• The rapid peak anticoagulant effect of dabigatran (1-3 hours after ingestion) requires cautious postoperative resumption, similar to resuming treatment-dose LMWH 1
• Consider potential effects of postoperative bowel dysmotility and acid-suppressive therapy on dabigatran absorption 1

Common Pitfalls to Avoid

• Avoid unnecessary bridging: Unlike warfarin, dabigatran does not require bridging therapy due to its predictable pharmacokinetics and short half-life 1
• Avoid premature resumption after high bleeding risk procedures, as this increases bleeding risk 1
• Avoid delayed resumption after low bleeding risk procedures in high thrombotic risk patients 1
• Avoid full-dose resumption immediately after high bleeding risk procedures; consider reduced initial dosing 1