No Bridging Required for DOACs Postoperatively
Bridging with enoxaparin (Clexane) is NOT necessary for patients on DOACs postoperatively and should not be administered. 1
Why DOACs Don't Require Bridging
The rapid offset and rapid onset of action of DOACs completely obviate the need for heparin bridging with short-acting anticoagulants such as unfractionated heparin or LMWH in the perioperative setting. 1
Evidence demonstrates that bridging DOACs with LMWH significantly increases bleeding risk without reducing thromboembolic events:
In the RE-LY trial subanalysis, patients receiving perioperative LMWH bridging had major bleeding rates of 6.5% vs 1.8% without bridging (P < .001), with no significant effect on stroke/systemic embolism (0.5% vs 0.3%; P = .46). 1
A prospective registry of 901 DOAC-treated patients showed bridging increased major bleeding risk (OR = 4.6; 95% CI: 1.1-9.9) with no thromboembolic benefit (OR = 1.9; 95% CI: 0.7-5.4). 1
Meta-analysis data revealed a threefold higher incidence of major bleeding with bridging (4.8% vs 1.6%), with no differences in stroke/systemic embolism rates. 1
Postoperative DOAC Resumption Protocol
For low-to-moderate bleeding risk procedures:
- Resume DOACs at least 24 hours after the procedure 1
- Ensure adequate surgical hemostasis before resumption 1
For high bleeding risk procedures:
- Resume DOACs 48-72 hours after the procedure 1
- Assess wound drainage and surgical site for bleeding before resumption 1
Critical Timing Consideration
DOACs achieve peak anticoagulant effect within 1-3 hours after administration, making cautious timing essential postoperatively. 1 Flexibility with resumption timing is warranted if patients develop greater than expected postoperative bleeding. 1
Exception: VTE Prophylaxis in High-Risk Patients
In selected patients at high risk for postoperative VTE (e.g., abdominopelvic cancer surgery, hip/knee replacement), low-dose LMWH (enoxaparin 40 mg daily or dalteparin 5,000 IU daily) may be given for the first 48-72 hours postoperatively until DOAC resumption. 1 This is VTE prophylaxis, NOT bridging anticoagulation. 1
Contrast with Warfarin Management
This guidance differs fundamentally from warfarin management, where bridging may be indicated in high thrombotic risk patients (mechanical valves, recent stroke/TIA). 1, 2 The key distinction is that DOACs have predictable pharmacokinetics with rapid onset/offset, eliminating the prolonged subtherapeutic period seen with warfarin. 1
Common Pitfall to Avoid
Do not extrapolate warfarin bridging protocols to DOAC patients—this practice increases bleeding complications without clinical benefit. 1 The French Working Group on Perioperative Hemostasis explicitly states that preoperative bridging by UFH or LMWH is not recommended for DOACs. 1