Pradaxa Discontinuation Before Hip Surgery
For hip surgery, discontinue Pradaxa 4 days (96 hours) before the procedure if creatinine clearance is ≥50 mL/min, or 5 days (120 hours) if CrCl is 30-50 mL/min. 1
Risk Classification
Hip replacement is classified as a high hemorrhagic risk procedure requiring minimal to no residual anticoagulant effect at the time of surgery, as surgical hemostasis cannot be performed safely with residual anticoagulation. 1
Specific Hold Duration Based on Renal Function
The timing of Pradaxa discontinuation is critically dependent on creatinine clearance (calculated using Cockcroft-Gault formula), as dabigatran has predominant renal elimination:
- CrCl ≥50 mL/min: Stop Pradaxa 4 days (96 hours) before surgery 1, 2
- CrCl 30-50 mL/min: Stop Pradaxa 5 days (120 hours) before surgery 1, 2
- CrCl <30 mL/min: Stop Pradaxa 5 days (120 hours) before surgery, though dosing recommendations for this population are limited 1, 2
The FDA label states to discontinue 1-2 days for CrCl ≥50 mL/min or 3-5 days for CrCl <50 mL/min before invasive procedures, but this range is insufficient for high-risk procedures like hip surgery—always use the longer end of the range or exceed it. 2
Additional Risk Factors Requiring Extended Hold
Consider extending the discontinuation period up to 5 days in patients with any of the following risk factors for drug accumulation:
- Age >80 years 1, 3
- Concomitant P-glycoprotein inhibitors (e.g., verapamil, amiodarone, dronedarone, quinidine) 1, 3, 2
- Any additional risk of drug accumulation 1, 3
Critical Timing Considerations
Obtain a recent creatinine clearance measurement before determining the hold duration—this is non-negotiable, as failing to do so can lead to inadequate drug clearance and catastrophic bleeding. 1, 3
The goal is to achieve 4-5 drug half-lives of interruption for high-bleed-risk procedures; dabigatran's terminal half-life is 12-14 hours in elderly patients, making the 4-5 day window physiologically appropriate. 3
Bridging Anticoagulation
Do not use preoperative heparin bridging (LMWH or UFH) when discontinuing Pradaxa for hip surgery—bridging increases bleeding risk without clear benefit and is not recommended. 1, 3 The only exception is patients at very high thrombotic risk, which should be determined on a case-by-case basis. 1, 3
Biological Monitoring
Routine biological monitoring of dabigatran levels is not needed when recommended interruption periods are followed. 1 However, monitoring may be considered on a case-by-case basis if there is concern about residual anticoagulant effect, particularly in patients with renal impairment or those requiring urgent procedures. 3
Resumption After Surgery
Resume Pradaxa 48-72 hours after hip surgery, provided adequate hemostasis has been established and there is no ongoing bleeding. 1, 3, 2
If VTE prophylaxis is needed immediately postoperatively before resuming Pradaxa, use LMWH or fondaparinux starting at least 6 hours after surgery. 1
Critical Pitfalls to Avoid
- Never perform neuraxial anesthesia (spinal or epidural) in patients with possible residual dabigatran concentration due to insufficient discontinuation time, particularly in patients >80 years or with renal failure. 1
- Do not use the shorter 1-2 day hold time from the FDA label for high-risk procedures like hip surgery—this is grossly inadequate. 2
- Do not forget to account for P-glycoprotein inhibitors, which can significantly increase dabigatran levels and require extended hold times. 1, 3, 2
Emergency Reversal
If emergency surgery is required before adequate drug clearance, idarucizumab (Praxbind) is available as a specific reversal agent for dabigatran. 2, 4