Pradaxa (Dabigatran) Preoperative Discontinuation
Hold Pradaxa for 1-2 days before low bleeding risk procedures if CrCl ≥50 mL/min, or 3-5 days if CrCl <50 mL/min; for high bleeding risk procedures, hold 4 days if CrCl >50 mL/min or 5 days if CrCl 30-50 mL/min. 1
Renal Function-Based Protocol
The duration of Pradaxa discontinuation is critically dependent on creatinine clearance due to its 80% renal elimination 2:
Standard/Low-to-Moderate Bleeding Risk Procedures
- CrCl ≥50 mL/min: Discontinue 1-2 days (24-48 hours) before surgery 1
- CrCl 30-50 mL/min: Discontinue 3-5 days before surgery 1
- CrCl <30 mL/min: Discontinue 5 days before surgery 1
High Bleeding Risk Procedures
- CrCl >50 mL/min: Discontinue 4 days before surgery 2
- CrCl 30-50 mL/min: Discontinue 5 days before surgery 2
Very High Bleeding Risk Procedures
- Intracranial neurosurgery or neuraxial anesthesia: Discontinue up to 5 days before the procedure regardless of renal function 2
- The FDA label emphasizes considering longer discontinuation times for major surgery, spinal puncture, or epidural catheter placement where complete hemostasis is required 1
Bleeding Risk Classification
Low bleeding risk procedures include those where adequate local hemostasis can be achieved, such as dental extractions, arthroscopy, and colonoscopy with biopsy 3:
- For tooth extractions specifically: Hold 1 day (24 hours) if CrCl ≥50 mL/min, or 2 days if CrCl <50 mL/min 3
High bleeding risk procedures include cardiac surgery, intracranial surgery, spinal surgery, surgery in highly vascular organs, and any major operation 2:
- These require the longer discontinuation periods outlined above
Critical Management Points
Bridging Anticoagulation
- Do NOT bridge with heparin or LMWH - Pradaxa's rapid offset eliminates the need for bridging, and bridging increases bleeding risk without reducing thrombotic events 3
- The French Working Group on Perioperative Hemostasis no longer recommends routine bridging 2
Special Populations
- Age >80 years or renal impairment: Strongly avoid neuraxial procedures without adequate discontinuation time due to increased drug accumulation 2
- Concomitant P-glycoprotein inhibitors: Avoid in patients with CrCl <50 mL/min, as these drugs increase dabigatran levels 1
Postoperative Resumption
- Resume Pradaxa at least 12-24 hours after surgery once adequate hemostasis is achieved 1
- For high bleeding risk procedures, consider delaying resumption to 2-3 days postoperatively 2
Emergency Surgery
- If surgery cannot be delayed, use idarucizumab (specific reversal agent) for emergency procedures requiring immediate reversal of anticoagulation 1
- The increased bleeding risk must be weighed against the urgency of intervention 1
Common Pitfalls
- Failure to assess renal function: Always calculate CrCl using Cockcroft-Gault formula before determining discontinuation timing 2
- Using INR or aPTT for timing: These tests are unreliable for monitoring dabigatran and should not guide surgical clearance 2
- Unnecessary bridging: This increases bleeding risk without benefit given dabigatran's rapid pharmacokinetics 3