Perioperative Direct Oral Anticoagulant (DOAC) Management

Chapter: Perioperative Direct Oral Anticoagulant (DOAC) Management
McMaster Section Editor(s): James Douketis
McMaster Author(s): James Douketis
Additional Information

The perioperative management of patients who are receiving a direct oral anticoagulant (DOAC) and require an elective surgery or invasive procedure is a common clinical problem. In assessing these patients, the task of the clinician is (1) to determine if DOAC interruption is needed, and (2) to provide advice on how to interrupt and resume DOACs perioperatively.

INDICATIONSTop

There are several minor procedures, classified as being minimal bleeding risk, where DOACs can be continued without complete interruption (Figure 3.1-1). These procedures consist of dental extractions, endodontic (root canal) procedures, skin biopsies, phacoemulsification (cataract) surgery, and selected colonoscopies. Implantation of a cardiac pacemaker or internal defibrillator (ICD) as well as cardiac catheterization can be done without stopping DOACs (Table 3.1-7). However, there are several points to note in the management of such patients:

1) Any of these procedures could be considered as having a higher bleeding risk, warranting full anticoagulant interruption. For example, a tooth extraction in a patient with poor dental or gingival hygiene or cataract surgery with retrobulbar instead of topical anesthesia may not be considered minimal bleeding risk.

2) It is suggested to skip the morning DOAC dose just before the procedure, because if a DOAC is taken on the day of the procedure the peak anticoagulant effect—occurring 1 to 3 hours after intake—may coincide with the timing of the procedure and may increase the risk for bleeding.

3) In patients having coronary angiography using a femoral approach, continuing DOACs may not be advisable as such patients are at increased risk for developing an inguinal hematoma or false aneurysm.

4) In patients having a colonoscopy, DOACs can be continued in situations where the need for polypectomy is unlikely, whereas interruption would be required if the likelihood of polypectomy is higher. A discussion with the clinician performing the colonoscopy can ensure optimal anticoagulant management.

5) In dental procedures oral tranexamic acid mouthwash can be used just before and 2 to 3 times daily for 1 to 2 days after the procedure to reduce bleeding, since such bleeding may not be clinically important but may cause distress to patients.

MANAGEMENTTop

In patients who are receiving a DOAC and require treatment interruption for an elective surgery or invasive procedure, patient management depends on the bleeding risk associated with the surgery or procedure. The thromboembolic risk is less important because DOACs have a rapid offset and onset of action (cessation and resumption of the therapeutic effect), and a short (2-4 days) interruption interval perioperatively is unlikely to substantially increase the risk for thromboembolism.

A high-bleeding-risk surgery or procedure comprises major abdominal surgery (eg, cancer resection); major thoracic surgery; major orthopedic surgery; and any cardiac, spinal, or intracranial surgery. Any patient having neuraxial anesthesia is classified as high bleeding risk because of the small but important risk for epidural hematomas, which can cause lower limb paralysis. A low- to moderate-bleeding-risk surgery or procedure includes most surgeries that typically are <1 hour in duration and do not involve neuraxial anesthesia.

1. Preoperative management:

1) Patients having a high-bleeding-risk surgery or procedure should discontinue DOACs for 2 full days (ie, ≥48 hours) before the procedure, which in most cases corresponds to a 60- to 68-hour interval between the last DOAC dose and the time of surgery (Figure 3.1-2). For example, if a patient is having a high-bleeding-risk surgery or procedure on a Monday at 8:00 and takes their last DOAC dose at 18:00 on the preceding Friday, this represents a 62-hour interval between the last dose and the surgery. With this interruption interval, there would be minimal or no residual anticoagulant effects at the time of the surgery, given the 12- to 15-hour half-life of DOACs.

2) Patients having a low- to moderate-bleeding-risk surgery or procedure should discontinue DOACs for 1 full day before the procedure, which would correspond to a 36- to 42-hour interval between the last DOAC dose and the surgery (Figure 3.1-3).

3) Patients having a minimal-bleeding-risk surgery or procedure in most situations should not take DOACs on the day of the procedure. Alternatively, one can defer that day’s dose until the evening (in the case of a once-daily regimen) or just skip the morning dose and resume the evening dose (in the case of a twice-daily regimen).

In all patients no DOAC is taken on the day of the surgery or procedure. The exception to this approach is patients who are receiving dabigatran and have moderately to severely impaired renal function (creatinine clearance <50 mL/min): Because dabigatran is excreted mainly by the kidney (80%), a longer interruption interval of 4 days is needed before a high-bleeding-risk surgery or procedure and 2 days before a low- to moderate-bleeding-risk surgery/procedure.

2. Postoperative management: After the surgery or procedure, the resumption of DOACs should, in effect, mirror the preoperative interruption. After a low- to moderate-bleeding-risk surgery or procedure, ≥24 hours should elapse before resuming DOACs (ie, resume the day after the surgery/procedure) and 48 to 72 hours should elapse before resuming DOACs after a high-bleeding-risk surgery/procedure.

The overall management approach can be summarized as: “1 day off before and after a low- to moderate-bleeding-risk surgery/procedure and 2 days off before and after a high-bleeding-risk surgery/procedure.” The exception to this approach is patients who are receiving dabigatran with a creatinine clearance <50 mL/min, as they require an additional 1 to 2 days of interruption before a surgery or procedure to allow adequate time for drug clearance.

There are some points to note about postoperative DOAC management:

1) The 48- to 72-hour resumption interval can be extended if the postoperative bleeding is more than expected, which is important because the full anticoagulant effect of DOACs is almost immediate after oral intake.

2) In patients who are unable to take medications by mouth and who are at high risk for venous thromboembolism, low-dose subcutaneous low-molecular-weight heparin (LMWH) can be given for the first 1 to 3 postoperative days.

Tables and FiguresTop

Table 3.1-7. Perioperative bleeding risk categoriesa

Surgery/procedure

Minimal bleeding risk

High bleeding risk

Gastrointestinal and genitourinary procedures

– Colonoscopyb

– Gastroscopyb

– Sigmoidoscopyb

– Capsule endoscopyc

– Push enteroscopy

– Barrett esophagus ablation

Major abdominopelvic surgery: hepatobiliary cancer resection, pancreatic cancer or pseudocyst resection, colorectal and gastric cancer resection, diverticular disease resection, inflammatory bowel disease resection, renal cancer resection, bladder cancer resection, endometrial cancer resection, ovarian cancer resection, radical prostatectomy

 

Cardiac procedures

– Permanent pacemaker implantation or battery change

– Internal cardiac defibrillator implantation or battery change

– Atrioventricular node ablation

– Coronary artery angiography (radial approach)

Major cardiac surgery (coronary artery bypass, valve replacement or repair)

Major thoracic surgery

 

– Lobectomy, pneumonectomy

– Esophagectomy

Major vascular surgery

 

– Aortic aneurysm repair

– Aortobifemoral bypass, popliteal bypass

– Carotid endarterectomy

Major orthopedic surgery

 

– Hip arthroplasty or hip fracture repair

– Knee arthroplasty or tibial osteotomy

– Shoulder arthroplasty

– Metatarsal osteotomy

Other major cancer or reconstructive surgery

 

– Head and neck cancer surgery

– Reconstructive facial, abdominal, or limb surgery

Dental procedures

– Tooth extraction (≤2 extractions)

– Endodontic (root canal) procedure

 

Skin procedures

Skin biopsy

 

Eye procedures

Phacoemulsification (cataract)

 

Neuraxial anesthesia

 

Any surgery requiring neuraxial anesthesia or injection (including epidural)

Intracranial or neuraxial surgery

 

– Brain cancer resection

– Laminectomy or neuraxial tumor resection

– Intracranial (subdural, epidural) bleeding evacuation

a Examples of surgeries with minimal and high risk of bleeding. A low- to moderate-bleeding-risk surgery or procedure includes most surgeries that typically are <1 hour in duration and do not involve neuraxial anesthesia.

b Assuming no polypectomy is expected.

c Assuming no sphincterotomy is expected.

 

Figure 3.1-1. Perioperative management of direct oral anticoagulants: surgery/procedure with minimal bleeding risk. See text for exceptions.

Figure 3.1-2. Perioperative management of direct oral anticoagulants: surgery/procedure with high bleeding risk.

Figure 3.1-3. Perioperative management of direct oral anticoagulants: surgery/procedure with low to moderate bleeding risk.

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