What is the discontinuation guide for Novel Oral Anticoagulants (NOACs) prior to surgery?

From the Guidelines

NOACs should be discontinued before surgery based on the specific medication, renal function, and bleeding risk of the procedure, with a pharmacokinetic-based approach guiding the interruption interval, as recommended by the most recent guidelines 1. When considering the discontinuation of NOACs prior to surgery, several factors must be taken into account, including the type of NOAC, the patient's renal function, and the bleeding risk associated with the procedure.

• For patients with normal renal function, a 48-hour interruption is often sufficient for standard bleeding risk procedures, while high bleeding risk procedures may require a longer interruption period.
• The timing of NOAC discontinuation is critical, as these medications have relatively short half-lives but can significantly increase bleeding risk during surgery.
• Laboratory testing before surgery is generally not required, as NOACs have predictable pharmacokinetics, and bridging therapy with heparin is typically unnecessary for most patients on NOACs.
• After surgery, NOACs can usually be resumed 24-48 hours post-procedure for standard bleeding risk and 48-72 hours for high bleeding risk procedures, once adequate hemostasis is achieved.
• For urgent procedures, consider specific reversal agents if available, such as idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors, as recommended by recent guidelines 1. Key considerations for specific NOACs include:
• Dabigatran: requires 48-96 hours of interruption depending on kidney function, with longer intervals for patients with impaired renal function.
• Apixaban and rivaroxaban: can be stopped 48 hours before surgery for standard bleeding risk procedures, with extended interruption for high bleeding risk procedures.
• Patients with severely impaired kidney function (CrCl <30 mL/min) may require longer periods off medication, and those with hepatic dysfunction or taking interacting medications may also need individualized management, as outlined in recent guidelines 1.

From the FDA Drug Label

If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, XARELTO should be stopped at least 24 hours before the procedure to reduce the risk of bleeding [see Warnings and Precautions (5. 2)] If possible, discontinue dabigatran etexilate capsules in adults 1 to 2 days (CrCl ≥50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before invasive or surgical procedures because of the increased risk of bleeding

Discontinuation of NOACs prior to surgery:

• For rivaroxaban (XARELTO), stop at least 24 hours before the procedure 2.
• For dabigatran etexilate, discontinue 1 to 2 days (CrCl ≥50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before invasive or surgical procedures 3. Key considerations:
• Weigh the increased risk of bleeding against the urgency of intervention.
• Consider longer times for patients undergoing major surgery, spinal puncture, or placement of a spinal or epidural catheter or port.
• Restart anticoagulation as soon as medically appropriate after the procedure.

From the Research

NOACs Discontinuation Guide Prior to Surgery

• The management of new oral anticoagulants (NOACs) during invasive or surgical interventions requires consideration of the patient's thromboembolic risk and the pharmacokinetic profiles of the specific NOAC being used 4.
• In patients with low or minimal bleeding risk, surgical procedures can be scheduled at the beginning of the next dosing interval or omitted, with only 2-3 NOAC doses not administered 4.
• For patients with moderate and high risk of bleeding, a NOAC break of 24-48 hours prior to surgery is recommended to allow for the decay of the active metabolite 4.
• In patients with low to intermediate risk for thromboembolism, no bridging is necessary if the "unprotected" time (NOAC break) is less than 4-5 days 4.
• The use of specific reversal agents, such as idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban, may be considered in emergency or urgent surgeries where the patient is taking NOACs 5.
• Elective surgeries can be performed 2 days after cessation of NOAC, regardless of the type of NOAC, with neuraxial anesthesia performed 3 days after cessation of NOACs 5.
• Generally, NOACs should be stopped 2 to 5 days before a procedure, depending on bleeding risk, and resumed at least 24 hours after surgery 6.
• Preoperative coagulation testing is generally unnecessary for patients taking NOACs 6.

Pharmacokinetics and Pharmacodynamics of NOACs

• NOACs, including dabigatran, rivaroxaban, apixaban, and edoxaban, have a rapid onset and elimination via the liver and kidneys, with a half-life between 5 and 14 hours 7.
• The extent of renal elimination varies among NOACs, with dabigatran having the highest renal elimination (80% or more) and apixaban having the lowest (25%) 7.
• Due to the reliable pharmacokinetics and pharmacodynamics of NOACs, no routine laboratory monitoring is necessary, although dedicated laboratory assays are available for emergencies and specific conditions 7.

Management of NOACs in Emergency and Trauma Surgery

• The management of patients on NOACs in emergency or trauma surgery relies on best supportive care in combination with blood products and/or specific antidotes as required 8.
• Familiarity with new reversal agents is essential, but further evidence on their indications, safety, and efficacy, as well as consensus guidelines, are warranted prior to widespread adoption 8.