How long should blood thinners, such as warfarin (Warfarin), novel oral anticoagulants (NOACs) like rivaroxaban (Rivaroxaban) or apixaban (Apixaban), and aspirin (Acetylsalicylic acid), be discontinued before hip replacement surgery?

Preoperative Discontinuation of Blood Thinners Before Hip Replacement Surgery

For hip replacement surgery, discontinue warfarin 4 days preoperatively, NOACs (rivaroxaban, apixaban) 48 hours preoperatively if creatinine clearance ≥50 mL/min (longer if renal impairment), and aspirin can generally be continued without interruption.

Warfarin Management

Warfarin should be discontinued approximately 4 days before hip replacement surgery to allow the INR to return to normal range (≤1.5). 1

• Monitor INR daily after warfarin discontinuation until it reaches ≤1.5 before proceeding with surgery 1
• For patients at high thromboembolic risk (mechanical mitral valve, recent VTE within 3 months, prior stroke), initiate full-dose heparin (UFH or LMWH) when INR falls below therapeutic range, then discontinue heparin 5 hours before surgery (or LMWH 12-24 hours before) 1
• For patients at low-to-intermediate thromboembolic risk (atrial fibrillation without prior stroke, bileaflet aortic valve), bridging anticoagulation is not routinely required 1
• If urgent reversal is needed, administer 2.5-5.0 mg vitamin K intravenously or orally 1

Direct Oral Anticoagulants (NOACs)

Rivaroxaban

Stop rivaroxaban at least 48 hours before hip replacement surgery if creatinine clearance (CrCl) is ≥50 mL/min. 1, 2

• For moderate renal impairment (CrCl 30-49 mL/min), extend discontinuation to 48-72 hours 1, 2
• The 24-hour minimum hold time from FDA labeling is insufficient for high bleeding risk procedures like hip replacement 2
• No preoperative bridging with heparin is required 1, 2
• Obtain recent creatinine clearance measurement before determining hold duration 1, 2

Apixaban

Discontinue apixaban at least 48 hours prior to hip replacement surgery for patients with normal renal function. 1, 3

• The FDA label recommends discontinuation at least 48 hours prior to elective surgery with moderate or high bleeding risk 3
• For patients requiring complete hemostasis (major surgery like hip replacement), discontinuation for ≥48 hours is necessary 1
• No bridging anticoagulation is needed during the interruption period 1
• Consider extending to 72 hours in patients with renal impairment, age >80 years, or concomitant P-glycoprotein inhibitors 1

Dabigatran

Hold dabigatran for 2-4 days before hip replacement surgery depending on renal function. 4

• For CrCl ≥50 mL/min: hold for 2 days (48 hours) 4
• For CrCl 30-50 mL/min: hold for 4 days (96 hours) 4
• For CrCl <30 mL/min: hold for 4-5 days 4
• Consider longer interruption periods (up to 5 days) for patients >80 years old or taking P-glycoprotein inhibitors 4
• Ensure recent creatinine clearance measurement is available before determining hold duration 4
• No preoperative heparin bridging is recommended 4

Aspirin and Antiplatelet Agents

Aspirin monotherapy can generally be continued through hip replacement surgery without interruption. 1, 5

• Bleeding during hip replacement can usually be controlled with surgical hemostasis, allowing continuation of aspirin 1
• If aspirin must be discontinued due to specific bleeding concerns, stop 7 days preoperatively to allow platelet function recovery 5
• Dual antiplatelet therapy (aspirin plus clopidogrel) should be discontinued, with clopidogrel stopped 5-7 days before surgery 5

Critical Timing Considerations and Common Pitfalls

Always obtain recent renal function testing (creatinine clearance) before determining NOAC hold duration, as renal impairment significantly prolongs drug elimination. 1, 4, 2

• Hip replacement is classified as a high hemorrhagic risk procedure requiring minimal residual anticoagulant effect 1, 4, 2
• Do not use the shorter 24-hour hold times recommended for low bleeding risk procedures 2
• Biological monitoring of NOAC levels is generally not needed when recommended interruption periods are followed 1, 2
• Check INR on the day of surgery for warfarin patients; consider postponing if INR >1.5 1

Resumption of Anticoagulation Postoperatively

Resume anticoagulation 48-72 hours after hip replacement surgery once adequate hemostasis is established and there is no ongoing bleeding. 1, 4, 2

• For warfarin: resume on postoperative day 1-2 with maintenance dose plus 50% boosting dose for two consecutive days, continue LMWH/UFH bridging until INR is therapeutic for >48 hours 1
• For NOACs: resume at standard dose 48-72 hours postoperatively 1, 4, 2
• If immediate VTE prophylaxis is needed postoperatively before resuming oral anticoagulation, use LMWH or fondaparinux starting at least 6 hours after surgery 2