From the Guidelines
Warfarin should be discontinued at least 5 days before elective surgery to minimize the risk of bleeding complications, as recommended by the American College of Chest Physicians clinical practice guideline 1. This timeframe allows for the anticoagulant effect of warfarin to diminish, reducing the risk of perioperative bleeding. The decision to discontinue warfarin should be based on the individual patient's risk of thromboembolism and the type of surgery being performed.
Considerations for Discontinuation
- For procedures with low bleeding risk, such as arthroscopy or cutaneous biopsies, warfarin may be discontinued 3-4 days before surgery 2.
- For high bleeding risk procedures, such as major surgery with extensive tissue injury or cancer surgery, warfarin should be discontinued 5-7 days before surgery 2.
- Patients with high thrombotic risk may require bridging therapy with low molecular weight heparin (LMWH) such as enoxaparin when the INR falls below 2.0, continuing until approximately 24 hours before surgery 2.
Monitoring and Resumption
- An INR check should be performed the day before or the morning of surgery to ensure it has decreased to an acceptable level (typically below 1.5 for most surgeries, or below 1.2 for neurosurgery or other procedures with critical bleeding risk) 2.
- Resumption of warfarin typically occurs 12-24 hours after surgery if hemostasis is adequate, often at the previous maintenance dose 2.
Individualized Approach
- Patients should receive clear instructions about this schedule from their healthcare provider, as individual factors including kidney function, age, and specific surgical procedure may necessitate adjustments to this general protocol 1.
From the FDA Drug Label
When discontinuing warfarin sodium tablets even for a short period of time, the benefits and risks should be strongly considered. Some dental or surgical procedures may necessitate the interruption of warfarin sodium tablets therapy PT/INR determination is recommended just prior to any dental or surgical procedure.
The decision to discontinue warfarin before surgery should be made on a case-by-case basis, considering the benefits and risks of interrupting anticoagulation therapy. The timing of discontinuation is not explicitly stated in the drug label, but it is recommended to determine the PT/INR just prior to any dental or surgical procedure.
- The management of patients who undergo dental and surgical procedures requires close liaison between attending physicians, surgeons, and dentists 3.
- Discontinuation of warfarin sodium tablets should be considered for some dental or surgical procedures, but the label does not provide specific guidance on when to discontinue warfarin before surgery.
From the Research
Discontinuation of Warfarin Before Surgery
- The decision to discontinue warfarin before surgery depends on various factors, including the type of surgery, the patient's risk of thromboembolism, and the risk of bleeding 4, 5.
- According to a study published in the Archives of Internal Medicine, warfarin was stopped 5 or 6 days before the procedure in patients with a mechanical heart valve, chronic atrial fibrillation, or embolic stroke who required interruption of warfarin therapy because of an invasive procedure 4.
- Another study published in the Cleveland Clinic Journal of Medicine suggests that most patients should stop taking warfarin 5 days before elective surgery, and most do not need to receive heparin in the perioperative period as a bridge to surgery 5.
- The American College of Chest Physicians recommends that patients with mechanical heart valves should have their warfarin therapy managed according to the type of valve and its position, as well as other risk factors for stroke 6.
Bridging Anticoagulation Therapy
- Low-molecular-weight heparin (LMWH) can be used as a bridging anticoagulant in patients who require temporary interruption of warfarin therapy 4, 7, 8.
- A systematic review and meta-analysis published in the Journal of Thrombosis and Haemostasis found that LMWHs are not approved for patients with mechanical heart valves, but temporary off-label use in this clinical setting is considered a valid treatment option 7.
- A prospective study published in Circulation found that bridging anticoagulation therapy with enoxaparin appears to be feasible during the high-risk period for thromboembolism after mechanical heart valve replacement 8.