How long should Coumadin (warfarin) be held prior to hip replacement surgery?

Warfarin Management Before Hip Replacement Surgery

Warfarin should be stopped 4 to 5 days before hip replacement surgery to allow the INR to return to normal (1.2) at the time of the procedure. 1

Risk Stratification Approach

The management of warfarin before hip replacement surgery depends on the patient's risk of thromboembolism:

Low-Risk Patients

• Patients with atrial fibrillation without history of stroke 1
• Patients without venous thromboembolic events for more than 3 months 1
• Patients with bileaflet mechanical valve in aortic position 1

Management for Low-Risk Patients:

• Stop warfarin 4-5 days before surgery 1
• Allow INR to fall to normal or near normal (1.3-1.5) by the time of surgery 1
• Resume warfarin postoperatively at maintenance dose 1
• Consider supplementing with low-dose heparin (5000 U) or LMWH subcutaneously every 12 hours if necessary 1

Moderate-Risk Patients

• Patients with history of venous thromboembolism within 3-6 months 1

Management for Moderate-Risk Patients:

• Stop warfarin 4-5 days before surgery 1
• Administer prophylactic doses of heparin (5000 U) or LMWH (3000 U) subcutaneously every 12 hours starting 2 days before procedure 1
• Restart prophylactic heparin or LMWH 12 hours postoperatively along with warfarin 1
• Continue combination until INR returns to therapeutic range (4-5 days) 1
• Delay heparin or LMWH for 24 hours or longer if high risk of postoperative bleeding 1

High-Risk Patients

• Patients with recent thromboembolic events (within 3 months) 1
• Patients with mechanical heart valve in mitral position 1
• Patients with older model cardiac valve (ball/cage) 1

Management for High-Risk Patients:

• Stop warfarin 4-5 days before surgery with close INR monitoring 1
• When INR falls below therapeutic range, administer therapeutic doses of heparin (15,000 U every 12 hours subcutaneously) or LMWH (100 U/kg every 12 hours) 1
• Discontinue heparin 24 hours before surgery or LMWH 12-24 hours before surgery 1
• For critical anticoagulation needs, consider hospital admission for continuous IV heparin (1300 U/h) stopped 5 hours before surgery 1
• Restart heparin or LMWH in prophylactic doses 12 hours postoperatively along with warfarin 1
• Continue until INR reaches therapeutic range 1

Alternative Approaches

For patients who need more rapid reversal of anticoagulation:

• Administer vitamin K 2.5 mg orally 2 days before procedure to reduce the period off warfarin to 2 days 1
• For urgent hip fracture surgery, low-dose intravenous vitamin K protocol can safely reverse warfarin within 18 hours 2

Postoperative Management

• Resume warfarin 12-24 hours after surgery when adequate hemostasis is achieved 3, 4
• For patients undergoing hip arthroplasty, consider using lower leg compression devices in addition to anticoagulation 5
• The preferred method of prophylaxis for elective hip replacement is LMWH rather than adjusted-dose warfarin 1

Common Pitfalls and Caveats

• Failure to account for patient's thromboembolism risk can lead to serious complications 1
• Insufficient time off warfarin may lead to excessive surgical bleeding 6
• Overly aggressive reversal in high-risk patients may lead to thromboembolism 1
• Elderly patients (>75 years) require lower warfarin doses and may have higher bleeding risk 1
• Patients with renal insufficiency may have prolonged LMWH half-life, requiring dose adjustment 1
• Inadequate bridging therapy for high-risk patients can lead to thromboembolic events 1

Early administration of vitamin K for hip fracture patients on warfarin is associated with earlier operative management and fewer postoperative complications 6, 2.