How long should anticoagulants (e.g. warfarin, apixaban (Eliquis), rivaroxaban (Xarelto)) be stopped before surgery in patients with normal or impaired renal function?

Anticoagulant Discontinuation Before Surgery

For warfarin, stop 5 days before surgery; for apixaban and rivaroxaban with normal renal function, stop 2-3 days before high-risk procedures; for dabigatran with normal renal function, stop 2 days before high-risk procedures, but extend to 5 days if creatinine clearance is 30-50 mL/min. 1, 2

Warfarin Management

Stop warfarin 5 days (4-5 days) before surgery to allow INR to normalize to <1.5. 3, 1, 2, 4

• Check INR prior to the procedure to confirm it is <1.5 before proceeding. 3, 1
• Resume warfarin on the evening of the procedure day with the usual maintenance dose. 3, 2
• For patients at high thrombotic risk (mechanical mitral valves, recent VTE within 3 months), bridging with therapeutic-dose LMWH may be indicated: start LMWH 2 days after stopping warfarin and give the last dose at least 24 hours before surgery. 3, 2
• Routine bridging is NOT recommended for atrial fibrillation patients without additional high-risk features. 1, 2

Direct Oral Anticoagulants (DOACs)

Apixaban and Rivaroxaban

For patients with normal renal function:

• Low-to-moderate bleeding risk procedures: Stop 1 day before surgery (omit 2 doses for twice-daily apixaban, 1 dose for once-daily rivaroxaban). 2
• High bleeding risk procedures (major surgery, neuraxial blockade): Stop 2-3 days before surgery. 3, 1, 2, 5

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. 5

For patients with renal dysfunction: Stop 3 days before major surgery or high bleeding risk procedures. 1

Dabigatran

For patients with CrCl ≥50 mL/min:

• Low-to-moderate bleeding risk procedures: Stop 1 day before surgery. 2
• High bleeding risk procedures: Stop 2 days before surgery. 3, 2

For patients with CrCl 30-50 mL/min:

• Low-to-moderate bleeding risk procedures: Stop 2 days before surgery. 2
• High bleeding risk procedures: Stop 4-5 days before surgery. 3, 1, 2

Dabigatran requires longer discontinuation periods than other DOACs due to its high renal dependence (80% renal clearance), with half-life extending from 12-17 hours in normal function to 28 hours with moderate renal impairment. 1

Resumption of Anticoagulation

For warfarin: Resume 12-24 hours after surgery when adequate hemostasis is achieved. 2, 4

For DOACs:

• Resume at least 24 hours after low-to-moderate bleeding risk procedures. 2
• Resume 48-72 hours after high bleeding risk procedures. 2
• DOACs achieve full anticoagulation within 3 hours of administration, so premature resumption significantly increases bleeding risk. 3

Low Bleeding Risk Procedures

For dental procedures, cataract surgery, and minor dermatologic procedures, warfarin can often be continued without interruption. 3, 2

For low-risk endoscopic procedures, omit only the morning dose of DOACs on the day of the procedure. 3

Critical Considerations

Always calculate creatinine clearance before determining DOAC discontinuation timing, as renal function directly affects drug clearance and required discontinuation duration. 1, 2

Bridging anticoagulation with LMWH is only indicated for patients with recent (<3 months) VTE or PE, mechanical mitral valves, or recent thromboembolism—NOT for routine atrial fibrillation patients. 1, 2

High bleeding risk procedures include neurosurgery, spinal surgery with neuraxial anesthesia, cardiac surgery, major vascular procedures, and any surgery where bleeding cannot be easily controlled. 3, 2