How long should anticoagulation therapy be held before a procedure in a patient with impaired renal function on warfarin (International Normalized Ratio (INR)) or novel oral anticoagulants (NOACs) such as apixaban (Eliquis) or rivaroxaban (Xarelto)?

How Long to Hold Anticoagulation Before a Procedure

For patients with impaired renal function, hold NOACs (apixaban, rivaroxaban) for 3 days (72 hours) before high-risk procedures, hold dabigatran for 5 days (120 hours), and stop warfarin 5 days before surgery with a target INR <1.5. 1

Warfarin Management

Stop warfarin approximately 5 days before major surgery or high-risk procedures to allow INR to normalize to <1.5. 1, 2

• The 5-day window accounts for warfarin's long half-life and allows adequate time for coagulation factor synthesis 2
• Check INR on the day before or morning of the procedure to confirm adequate reversal 3
• For emergency reversal, use prothrombin complex concentrate (PCC) 50 IU/kg 1

Common pitfall: Do not routinely administer vitamin K for INR >1.5 measured 1-2 days before surgery, as this can cause post-operative warfarin resistance; instead, allow natural normalization by continuing warfarin interruption 3

Novel Oral Anticoagulants (NOACs) in Renal Impairment

Apixaban and Rivaroxaban

For patients with impaired renal function undergoing high-risk procedures, stop apixaban or rivaroxaban 3 days (72 hours) before the procedure. 1

• These agents have half-lives of 5-13 hours with 25% (apixaban) and 33% (rivaroxaban) renal clearance 1
• The 3-day interruption ensures minimal residual anticoagulant effect at the time of surgery 1
• For low-risk procedures (dental, dermatologic), omit only the morning dose on the day of the procedure to allow biopsies at trough levels 4

Dabigatran

For patients with impaired renal function, stop dabigatran 5 days (120 hours) before major surgery or high-risk procedures. 1

• Dabigatran has the highest renal dependence among NOACs, with significantly prolonged half-life in renal impairment 1
• For patients with creatinine clearance (CrCl) 30-50 mL/min, stop dabigatran at least 72 hours (3 days) before the procedure 4
• Critical consideration: Dabigatran is contraindicated in patients with CrCl <30 mL/min 4
• If the patient is clinically deteriorating, check renal function before the procedure and consider quantitative measurement of anticoagulant intensity (Hemoclot assay for dabigatran) 4

Procedure-Specific Timing

High-Risk Procedures

For high-risk procedures (major surgery, neuraxial blockade, central venous access), use the extended discontinuation periods outlined above. 4, 1

• High-risk procedures include those with potential for bleeding into critical structures or requiring ongoing hemostasis 5
• The last dose of a DOAC should be taken 2 days (48 hours) before high-risk procedures in patients with normal renal function 4
• In renal impairment, extend this to 3 days for apixaban/rivaroxaban and 5 days for dabigatran 1

Low-Risk Procedures

For low-risk procedures (dental extractions, dermatologic procedures, ophthalmologic procedures), continue warfarin within therapeutic INR range or omit only the morning dose of NOACs. 4

• Most minor procedures can be safely performed while on warfarin with INR in therapeutic range 4
• For NOACs, omit the morning dose on the day of low-risk procedures to perform biopsies at trough levels 4

Algorithm for Decision-Making

1. Assess renal function: Calculate creatinine clearance (CrCl) or eGFR 4, 1
2. Classify procedure bleeding risk: High-risk (major surgery, neuraxial blockade) vs. low-risk (dental, dermatologic) 4, 1
3. Apply discontinuation timeline based on anticoagulant type:
   • Warfarin: Stop 5 days before, target INR <1.5 1, 2
   • Apixaban/Rivaroxaban with renal impairment: Stop 3 days before high-risk procedures 1
   • Dabigatran with renal impairment: Stop 5 days before high-risk procedures 1
   • All NOACs with normal renal function: Stop 2 days before high-risk procedures 4

Bridging Anticoagulation Considerations

Bridging anticoagulation with low molecular weight heparin is only indicated for patients with recent (<3 months) venous thromboembolism or mechanical heart valves, NOT for routine atrial fibrillation patients. 1, 4

• The BRIDGE trial demonstrated that routine bridging in atrial fibrillation patients increases bleeding risk without reducing thrombotic events 1
• High-risk patients requiring bridging include those with mechanical heart valves or recent VTE within 3 months 1, 4
• Important caveat: DOACs are contraindicated in mechanical heart valve patients 4

Resumption After Procedure

Resume anticoagulation 48-72 hours after high bleeding risk procedures once adequate hemostasis is established. 5, 4

• For warfarin, resume at usual maintenance dose on the evening of or day after the procedure 3
• For NOACs, no bridging is needed as therapeutic anticoagulation is achieved within 2-4 hours 5
• Earlier resumption (24 hours) is reserved only for low bleeding risk procedures 5
• Delay until 72 hours if there were intraoperative bleeding concerns or baseline bleeding risk is elevated 5