DOACs Do Not Require Bridging Anticoagulation
None of the direct oral anticoagulants (DOACs) require bridging with heparin or low-molecular-weight heparin (LMWH) when interrupted for procedures. 1
Why DOACs Don't Need Bridging
- The rapid offset and rapid onset of action of all DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) obviate the need for heparin bridging in perioperative settings 1
- DOACs have predictable pharmacokinetics with peak effects occurring 1-3 hours after intake, allowing for simple interruption and resumption schedules 1
- Evidence shows that bridging DOACs with heparin actually increases bleeding risk without reducing thromboembolic events 1
- In a subanalysis of the RE-LY trial with dabigatran patients, those who received perioperative LMWH bridging had higher major bleeding rates (6.5% vs 1.8%) with no significant reduction in stroke/systemic embolism (0.5% vs 0.3%) 1
DOAC Interruption Protocol Without Bridging
Apixaban and Rivaroxaban:
- For low-to-moderate bleeding risk procedures: stop 1 day before procedure 1
- For high bleeding risk procedures: stop 2 days before procedure 1
Edoxaban:
- For low-to-moderate bleeding risk procedures: stop 1 day before procedure 1
- For high bleeding risk procedures: stop 2 days before procedure 1
Dabigatran (requires special consideration due to renal clearance):
- For low-to-moderate bleeding risk procedures with CrCl ≥50 mL/min: stop 1 day before 1
- For low-to-moderate bleeding risk procedures with CrCl <50 mL/min: stop 2 days before 1
- For high bleeding risk procedures with CrCl ≥50 mL/min: stop 2 days before 1
- For high bleeding risk procedures with CrCl <50 mL/min: stop 4 days before 1
Resumption of DOACs After Procedures
- For low-to-moderate bleeding risk procedures: resume at least 24 hours after procedure 1
- For high bleeding risk procedures: resume 48-72 hours after procedure 1
- No bridging is needed during resumption phase 1
Special Considerations
- Unlike DOACs, warfarin may require bridging in patients at high thromboembolic risk 2
- Dabigatran and edoxaban require 5 days of parenteral lead-in therapy when initiating treatment for acute VTE, but this is not considered "bridging" in the traditional sense 1
- Rivaroxaban and apixaban have specific initiation dosing regimens for VTE (rivaroxaban 15 mg twice daily for 21 days; apixaban 10 mg twice daily for 7 days) but do not require parenteral lead-in therapy 1
Common Pitfalls to Avoid
- Unnecessarily bridging DOACs increases bleeding risk without reducing thrombotic events 1, 2
- Failing to account for renal function when interrupting dabigatran can lead to inadequate clearance before procedures 1
- Resuming DOACs too soon after high bleeding risk procedures (peak effect occurs 1-3 hours after intake) 1
- Confusing initiation protocols for new VTE treatment with perioperative bridging requirements 1
Evidence Quality
- The recommendation against bridging DOACs is supported by high-quality evidence from the American College of Chest Physicians clinical practice guidelines (2022) 1
- The PAUSE study demonstrated the safety of standardized DOAC interruption without bridging, with low rates of major bleeding and arterial thromboembolism 1
- Patient registries show increased bleeding risk (OR = 4.6) with no significant reduction in thromboembolic events when DOACs are bridged 1