When should oral anticoagulants (OACs), such as warfarin, apixaban (Eliquis), or rivaroxaban (Xarelto), be stopped before surgery?

Timing for Stopping Oral Anticoagulants Before Surgery

For direct oral anticoagulants (DOACs) like apixaban and rivaroxaban, stop 48 hours (2 days) before high bleeding risk surgery; for low bleeding risk procedures, stop 24 hours (1 day) before. For warfarin, discontinue 5 days preoperatively. 1, 2, 3

Warfarin Management

• Stop warfarin 5 days before surgery to allow INR to normalize below 1.5 1
• Check INR prior to the procedure to confirm it is <1.5 1
• Restart warfarin the evening of the procedure at the usual daily dose 1
• Bridging with low molecular weight heparin (LMWH) is NOT routinely recommended for most patients, including those with atrial fibrillation 1
• Consider bridging only for very high thrombotic risk patients (recent <3 months venous thromboembolism) 1

Direct Oral Anticoagulants (DOACs): Apixaban and Rivaroxaban

Low Bleeding Risk Procedures

• Stop DOACs the night before the procedure (approximately 24 hours) 1
• This applies regardless of whether the drug is taken once or twice daily 1
• Resume therapy 6 hours or more after the procedure if hemostasis is adequate 1, 4

High Bleeding Risk Procedures

• Stop rivaroxaban and apixaban 3 days (72 hours) before surgery when creatinine clearance is >30 mL/min 1
• The FDA label for apixaban specifies stopping at least 48 hours prior to elective surgery with moderate or high bleeding risk 2
• The FDA label for rivaroxaban recommends stopping at least 24 hours before the procedure 3
• The most conservative approach from French guidelines (3 days) should be followed for major surgery to ensure complete drug clearance 1

Very High Bleeding Risk (Intracranial Neurosurgery, Neuraxial Anesthesia)

• Extend discontinuation to 5 days for procedures like intracranial neurosurgery or spinal/epidural anesthesia 1
• This longer window is critical to avoid catastrophic bleeding in closed spaces 1

Dabigatran (Special Considerations)

• Renal function determines timing due to predominant renal elimination 1
• For CrCl >50 mL/min: Stop 4 days before high-risk surgery 1
• For CrCl 30-50 mL/min: Stop 5 days before high-risk surgery 1
• For low bleeding risk procedures: Stop 3 days before if CrCl >50 mL/min 1
• For endoscopic procedures with high bleeding risk and CrCl 30-50 mL/min: Stop 72 hours (3 days) before 1

Critical Pitfalls to Avoid

• Do NOT use bridging anticoagulation with heparin products when stopping DOACs—this increases bleeding risk without reducing thrombotic risk 1
• Do NOT perform neuraxial anesthesia if there is any possibility of residual DOAC levels, especially in elderly patients (>80 years) or those with renal impairment 1
• Do NOT resume full-dose anticoagulation until adequate hemostasis is established; if bleeding risk remains high, use prophylactic doses temporarily 4
• Do NOT ignore renal function when timing DOAC discontinuation—impaired clearance requires longer drug-free intervals 1, 4

Resumption After Surgery

• Resume DOACs 6-48 hours after surgery depending on bleeding risk and adequacy of hemostasis 1, 4
• For low bleeding risk: Resume as early as 6 hours post-procedure 1
• For high bleeding risk: Delay 24-48 hours until hemostasis is secure 4
• If oral intake is not possible, consider parenteral anticoagulation 3

Emergency Surgery Considerations

• For emergent surgery (<6 hours), consider reversal agents: prothrombin complex concentrate (PCC) 50 IU/kg for warfarin 1, idarucizumab for dabigatran, or andexanet-α for factor Xa inhibitors 5
• If surgery can be delayed 24-48 hours, allow natural drug clearance rather than using reversal agents 5
• Laboratory testing to measure DOAC levels may guide the need for reversal agents in urgent cases 5