When should anticoagulants (e.g. warfarin, apixaban (Eliquis), rivaroxaban (Xarelto)) be stopped before surgery in patients with Impaired renal function?

Anticoagulant Discontinuation Before Surgery in Patients with Impaired Renal Function

In patients with impaired renal function undergoing surgery, direct oral anticoagulants (DOACs) require extended discontinuation periods: apixaban and rivaroxaban should be stopped 3 days before major surgery or neuraxial blockade, while dabigatran requires 5 days of discontinuation due to its significant renal dependence. 1

Apixaban (Eliquis) and Rivaroxaban (Xarelto)

For patients with renal dysfunction:

• Major surgery, neuraxial blockade, or high bleeding risk procedures: Stop 3 days (72 hours) before surgery 1
• Minor procedures with low bleeding risk: Stop 24-48 hours before surgery 1
• These factor Xa inhibitors have half-lives of 5-13 hours and are less dependent on renal function than dabigatran (33% renal clearance for rivaroxaban, 25% for apixaban) 1

The FDA label for apixaban specifies discontinuation at least 48 hours prior to elective surgery with moderate-to-high bleeding risk, and at least 24 hours for low bleeding risk procedures 2

Specific Guidance by Renal Function for Apixaban:

• Moderate impairment (CrCl 30-50 mL/min): Last dose 3 days before major surgery (skip 4 doses) 1
• Normal or mild impairment (CrCl ≥50 mL/min): Last dose 2 days before major surgery (skip 2 doses) for minor procedures, 3 days for major procedures 1

Dabigatran

For patients with renal dysfunction, dabigatran requires the longest discontinuation period:

• Major surgery, neuraxial blockade, or renal dysfunction: Stop 5 days before surgery 1
• Normal renal function with minor procedures: Can be stopped 3 days before surgery 1
• Dabigatran's half-life is highly dependent on renal function (normally 48-72 hours, but extends to 16-18 hours even with moderate impairment) 1

Specific Guidance by Renal Function for Dabigatran:

• Severe impairment (CrCl 15-29.9 mL/min): Last dose 4 days before major surgery (skip 3 doses) 1
• Moderate impairment (CrCl 30-50 mL/min): Last dose 3 days before major surgery (skip 2 doses), or 5 days for high-risk procedures 1
• Normal or mild impairment (CrCl ≥50 mL/min): Last dose 3 days before major surgery 1

Warfarin

Warfarin management is independent of renal function:

• Stop warfarin approximately 5 days before surgery to allow INR to normalize 1, 3
• Target INR <1.5 before proceeding with surgery 1
• For emergency reversal, use prothrombin complex concentrate (PCC) 50 IU/kg 1

Bridging Anticoagulation Considerations

Bridging is NOT routinely recommended for most patients:

• Bridging with low molecular weight heparin is only indicated for patients with recent (<3 months) venous thromboembolism or pulmonary embolism 1
• Patients with atrial fibrillation on warfarin do NOT require routine bridging 1
• High-risk patients (mechanical heart valves, venous thromboembolism within 3 months) may require bridging 1

Critical Pitfalls to Avoid

Common errors in perioperative DOAC management:

• Underestimating renal impairment: Always calculate creatinine clearance; renal dysfunction dramatically prolongs DOAC half-lives, especially for dabigatran 1
• Inadequate discontinuation time: The 2014 AHA/ACC/HRS guidelines note that procedures requiring complete hemostasis (spinal/epidural, major surgery) require ≥48 hours discontinuation even with normal renal function 1
• Unnecessary bridging: Routine bridging increases bleeding risk without reducing thromboembolism in most patients 1
• Ignoring drug-specific differences: Dabigatran requires longer discontinuation than factor Xa inhibitors in renal impairment due to 80% renal clearance 1

Algorithm for Decision-Making

Step 1: Assess renal function (calculate CrCl) 1

Step 2: Classify procedure bleeding risk:

• High risk: Major surgery, neuraxial blockade, closed-space surgery 1
• Low risk: Minor procedures, dental work, skin procedures 1

Step 3: Apply discontinuation timeline:

• Apixaban/Rivaroxaban + renal impairment + high-risk procedure: 3 days 1
• Dabigatran + any renal impairment + high-risk procedure: 5 days 1
• Any DOAC + normal renal function + low-risk procedure: 1-2 days 1

Step 4: Determine bridging need:

• Only if recent (<3 months) VTE/PE or mechanical valve 1