In a patient on dabigatran (150 mg twice daily) scheduled for cataract extraction, should the anticoagulant be continued or held, and what peri‑operative timing is recommended based on renal function?

Dabigatran Management for Cataract Surgery

For a patient on dabigatran 150 mg twice daily undergoing cataract extraction, hold dabigatran for 1 day (skip 2 doses) if creatinine clearance is ≥50 mL/min, or hold for 2 days (skip 4 doses) if creatinine clearance is <50 mL/min; resume 24 hours postoperatively once hemostasis is achieved. 1

Preoperative Management: Timing Based on Renal Function

Cataract surgery is classified as a low-to-moderate bleeding risk procedure, which fundamentally determines the interruption strategy. 1, 2

For Patients with CrCl ≥50 mL/min:

• Hold dabigatran for 1 day before surgery (skip 2 doses before the procedure) 1
• This allows 2-3 half-lives to elapse, resulting in 80-86% of patients having no residual anticoagulant effect at the time of surgery 2, 3
• The half-life of dabigatran is 14-17 hours in patients with normal or mildly impaired renal function 1, 2

For Patients with CrCl <50 mL/min:

• Hold dabigatran for 2 days before surgery (skip 4 doses before the procedure) 1
• The extended interruption reflects dabigatran's prolonged half-life (16-18 hours) in moderate renal impairment 1
• This ensures adequate drug clearance before the procedure 2

Evidence Supporting Continuation vs. Interruption

While some older literature suggests that anticoagulants can be safely continued during cataract surgery 1, the most recent high-quality guideline evidence from the American College of Chest Physicians (2022) recommends brief interruption even for low-bleeding-risk procedures. 1

A key study found that DOAC continuation during low-bleed-risk procedures was associated with higher bleeding rates compared to interruption (OR = 0.62 for interruption; 95% CI: 0.41 to 0.95). 1 However, a small 25-patient observational study of DOAC continuation during cataract surgery reported no bleeding events. 1

The balance of evidence favors brief interruption given the minimal thrombotic risk with 1-2 day interruption and the documented bleeding reduction. 1

Postoperative Resumption

• Resume dabigatran 24 hours after cataract surgery (on the day after surgery) at the full dose of 150 mg twice daily 1, 2
• Ensure adequate hemostasis has been achieved before resumption 2
• No bridging anticoagulation is needed due to dabigatran's rapid onset of action (peak levels at 1-3 hours) 1

Critical Management Points

No Bridging Therapy Required:

• Do not use heparin or LMWH bridging 2
• Bridging with LMWH increases major bleeding risk (6.5% vs 1.8%; P < .001) without reducing thrombotic events 1

Anesthesia Considerations:

• Use topical or intracameral anesthesia rather than retrobulbar or peribulbar injection to minimize bleeding risk 4
• This approach is particularly important for anticoagulated patients 4

Monitoring Considerations:

• While routine monitoring is not required, if there is concern about residual anticoagulant effect, dilute thrombin time (dTT) or aPTT can be checked 3
• A standardized interruption protocol yields 80-86% of patients with no residual effect at surgery time 3

Common Pitfalls to Avoid

• Do not stop dabigatran for extended periods (>2 days for normal renal function): This unnecessarily increases thrombotic risk without additional bleeding benefit 1
• Do not resume full-dose dabigatran immediately postoperatively: Wait at least 24 hours to ensure hemostasis 1, 2
• Do not use bridging anticoagulation: This significantly increases bleeding risk without benefit 1
• Do not forget to assess renal function: Dabigatran management is critically dependent on creatinine clearance 1