When should I stop oral anticoagulants before a planned surgery, considering the specific drug, renal function, surgical bleeding risk, and the patient’s thromboembolic risk?

Perioperative Anticoagulation Management: When to Stop Before Surgery

Stop oral anticoagulants based on drug half-life, renal function, and surgical bleeding risk—using a standardized protocol that eliminates the need for bridging therapy in nearly all patients. 1, 2

Warfarin Management

• Stop warfarin 5 days before moderate-to-high bleeding risk surgery to allow adequate clearance (half-life 36-42 hours). 3
• Measure INR on the day of surgery and postpone if INR >1.5, as this indicates inadequate reversal. 3
• Reserve therapeutic-dose LMWH bridging only for the highest thrombotic risk patients: mechanical prosthetic valves, very high-risk atrial fibrillation (CHA₂DS₂-VASc ≥7 with prior stroke), or recent VTE <3 months with active thrombophilia. 1, 3
• When bridging is indicated, start LMWH 2 days after warfarin discontinuation (when INR falls below 2.0), using therapeutic dosing of 70 U/kg anti-Xa twice daily, with the last dose ≥12 hours before surgery. 3

Direct Oral Anticoagulants (DOACs)

Apixaban & Rivaroxaban

For high bleeding risk surgery (cardiac, intracranial/spinal, major abdominal, joint replacement):

• Normal or mild renal impairment (CrCl ≥50 mL/min): Stop 3 days (72 hours) before surgery, which allows 4-5 half-lives to elapse and results in ≤6% residual anticoagulant effect. 1, 2
• Moderate renal impairment (CrCl 30-50 mL/min): Stop 4 days before surgery for apixaban; rivaroxaban still requires only 3 days due to less renal dependence. 1, 2

For low-to-moderate bleeding risk surgery (arthroscopy, colonoscopy with biopsy, hernia repair):

• Stop 2 days (48 hours) before surgery regardless of renal function when CrCl ≥30 mL/min, leaving 2-3 half-lives and minimal residual effect. 1, 2

Dabigatran

Dabigatran requires longer interruption due to 80% renal clearance:

• Normal or mild renal impairment (CrCl ≥50 mL/min): Stop 3 days before low-risk surgery (skip 4 doses) or 4 days before high-risk surgery (skip 6 doses). 1, 4
• Moderate renal impairment (CrCl 30-50 mL/min): Stop 4 days before low-risk surgery (skip 6 doses) or 5 days before high-risk surgery (skip 8 doses). 1, 4
• The FDA label specifies discontinuing 1-2 days before surgery when CrCl ≥50 mL/min, or 3-5 days when CrCl <50 mL/min, with longer times for major surgery or neuraxial procedures. 4

Edoxaban

• Follow the same protocol as rivaroxaban and apixaban: stop 3 days before high-risk surgery and 2 days before low-risk surgery when CrCl >30 mL/min. 3

Critical Decision Points

Never use heparin bridging for DOACs—the PAUSE trial and multiple retrospective analyses demonstrate that bridging increases major bleeding risk to 2-5% without reducing thromboembolism (which remains 0.16-0.4% without bridging). 2, 5

Extend interruption periods when:

• Age >80 years, as drug clearance is delayed. 3
• Concomitant P-glycoprotein inhibitors (affects all DOACs): amiodarone, verapamil, dronedarone, ketoconazole. 3, 4
• Concomitant CYP3A4 inhibitors (affects rivaroxaban, apixaban, edoxaban): clarithromycin, ritonavir, itraconazole. 3
• Very high hemorrhagic risk procedures (intracranial, neuraxial): extend DOAC interruption up to 5 days. 3

Postoperative Resumption

Low-to-moderate bleeding risk procedures:

• Resume DOACs 24 hours after surgery at the usual therapeutic dose once adequate hemostasis is confirmed. 1, 2
• For twice-daily regimens (apixaban, dabigatran), resume the evening dose on the day of surgery if ≥6 hours have elapsed. 6, 2

High bleeding risk procedures:

• Resume DOACs 48-72 hours after surgery to allow complete wound hemostasis. 1, 2
• Consider reduced-dose initiation (apixaban 2.5 mg twice daily for 2-3 days) in patients at very high thrombotic risk, then transition to full dose. 2
• If therapeutic anticoagulation must be delayed beyond 48 hours, use prophylactic-dose LMWH (not therapeutic dose) until full-dose DOAC can be safely resumed. 2

For warfarin:

• Restart on postoperative day 1-2 with usual maintenance dose plus 50% boost for two consecutive days, continuing LMWH bridging (if used) until INR reaches therapeutic range. 3

Common Pitfalls to Avoid

• Do not proceed with neuraxial anesthesia (spinal/epidural) when any residual DOAC levels may be present, especially in elderly or renally impaired patients—catastrophic spinal hematoma can occur. 2, 3
• Do not resume therapeutic anticoagulation before 24 hours after low-risk surgery or 48-72 hours after high-risk surgery—premature resumption increases major bleeding risk up to 20% without reducing thrombotic events. 2, 3
• Do not use routine coagulation assays (INR, aPTT) to guide DOAC management—they are insensitive to residual drug levels and add no value when standardized interruption protocols are followed. 2, 5
• Do not assume normal drug clearance in elderly patients on warfarin—delayed decay may occur, requiring INR verification before surgery. 3
• Do not overlook drug interactions that prolong DOAC clearance—P-gp and CYP3A4 inhibitors mandate longer pre-operative interruption. 3, 4

Minimal-Risk Procedures

For minimal bleeding risk procedures (dental cleaning, simple dental fillings, minor dermatologic procedures, cataract surgery):

• Continue DOACs without interruption, as the thrombotic risk of stopping outweighs the minimal bleeding risk. 1, 3
• Warfarin can be continued if INR is within therapeutic range (typically ≤3.0). 1, 7