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Perioperative Management of Patients Receiving DOACs
TAKE-HOME MESSAGE
- This review presented a standardized approach based on procedure-related bleeding risk to guide the perioperative management of patients taking direct oral anticoagulants (DOACs) and undergoing elective procedures. Minimal-risk procedures may not require DOAC interruption, low- to moderate-risk procedures typically involve stopping DOACs 1 day before and restarting 1 day after the procedure, and high-risk procedures require a 2-day interruption. This strategy was associated with low rates of thromboembolism (0.2–0.4%) and major bleeding (1.0–2.0%).
- For patients taking DOACs in emergent or urgent surgical situations, clinicians should consider preoperative DOAC level testing to guide the use of reversal agents (prothrombin complex concentrates, idarucizumab, and andexanet alfa). Adopting standardized protocols for elective procedures, along with tailored approaches for emergent or urgent cases, can help optimize outcomes and minimize complications in this patient population.
abstract
This abstract is available on the publisher's site.
Access this abstract nowIMPORTANCE
Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.
OBSERVATIONS
For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.
CONCLUSIONS AND RELEVANCE
When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.
Additional Info
Disclosure statements are available on the authors' profiles:
Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review
JAMA 2024 Aug 12;[EPub Ahead of Print], JD Douketis, AC SpyropoulosFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Direct oral anticoagulants and perioperative management
Nowadays, many patients are taking direct oral anticoagulants (DOACs) for atrial fibrillation or venous thromboembolism, and many of them will need to have surgical procedures, visits with their dentists, or get a routine colonoscopy. In these situations, what should we do with the DOACs? Do we stop them and for how long? When do we restart?
When warfarin was the only agent of choice, it was a nightmare. Warfarin is an indirect inhibitor of the coagulation system. It does not directly block the clotting cascade. Instead, it blocks vitamin K recycling. Vitamin K is needed to activate the clotting factors. So, low vitamin K levels mean less active clotting factors. Therefore, an individual is less likely to form clots. The reduced vitamin K level affects at least four different clotting factors. In addition, warfarin interacted with many medications, and its effects were countered if the patient ate more vitamin K–containing foods. Anticoagulation with warfarin was very hard to predict and control even with INR testing. Furthermore, each dose adjustment would need several days before the full effect on the coagulation system was observed. And because warfarin is slow to kick in, we needed to use heparin while the effects of warfarin were ramping up.
The new DOACs directly block the clotting factor, so the anticoagulation effect comes on very quickly, with a peak effect around 2 to 3 hours. Rivaroxaban, apixaban, and edoxaban directly block factor Xa while dabigatran blocks factor IIa. Direct blocking means quick onset and also better predictability. Therefore, there is no need for heparin bridging in most cases and no need to check the levels of these medications. The half-life of a DOAC is around 8 to 12 hours, which means it leaves the body quickly and the anticoagulation effect also wanes quickly.
This review has included all the data regarding the perioperative management of patients receiving DOACs. The authors reviewed all the studies and examined strategies that minimize the risk of procedure-related bleeding while ensuring that the rate of thrombotic events did not increase.
The procedures were divided into three categories based on the risk of bleeding complications: low-, moderate- and high-risk. For low-risk procedures like cataract surgery, dental extractions, skin biopsies, radial access angiography, or pacemaker insertion, there is no need to stop the DOAC. However, If the DOAC is taken once a day, then the dose should be shifted to the evening. If the DOAC is dabigatran, which is taken twice daily, then the morning dose should be skipped.
For moderate-risk bleeding procedures, such as laparoscopic cholecystectomy, hernia repair, hysterectomy, angiography using femoral artery access, endoscopy with or without biopsy, colonoscopy with or without biopsy, then stop the DOAC a day before the surgery and restart the DOAC a day after the surgery. For dabigatran, if the creatinine clearance is below 50 mL/min, then the patient should stop dabigatran 2 days before surgery because dabigatran is cleared by the kidneys so an extra day is needed to get rid of it.
For high-risk bleeding procedures, such as spinal surgery, spinal or epidural anesthesia, cancer surgery, orthopedic surgery, chest surgery, abdominal surgery, transurethral prostate or bladder resections, kidney biopsy, deep nerve blocks, stop DOACs 2 days before the procedure. If there is no bleeding after the surgery, the patient can restart the DOAC on day 2 after surgery; however, most people will wait until day 3 after surgery to restart. For patients receiving dabigatran, if the creatinine clearance is below 50 mL/min, then the patients need to stop the medication 4 days before the surgery instead of just 2 days before.
For urgent surgery, when there is no time to stop the DOAC, checking the anticoagulant levels may be useful to decide whether an antidote is needed.
With these simple recommendations, the bleeding and thrombotic event risks were low and at acceptable rates. Please, have a look at the table in the article; it is very simple to use and very important to ensure the benefits of DOACs while minimizing risk.