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Table 4 Summary of recent propositions for perioperative management of DOACs

From: Perioperative management of patients on direct oral anticoagulants

DOAC Dabigatran Rivaroxaban - Apixaban Edoxaban
Bleeding risk of invasive procedure LOW
Bleeding risk
HIGH
Bleeding risk
LOW
Bleeding risk
HIGH
Bleeding risk
LOW
Bleeding risk
HIGH
Bleeding risk
GIHP (Groupe d’Intérêt en Hémostase Péri-opératoire) Preoperative interruption
No bridging (except patients with high risk of TE)
CrCl ≥50 ml/min Last dose
≥ 24 h before surgery
Last dose
4 days before surgery
Last dose
≥ 24 h before surgery
Last dose
3 days before surgery
Last dose
≥ 24 h before surgery
Last dose
3 days before surgery
CrCl >30 ml/min Last dose
5 days before surgery
For very high risk procedure (neuraxial anaesthesia) Last dose 5 days before surgery
Resumption after invasive procedure or surgery   LOW Bleeding Risk:
Resume minimum 6 h after invasive procedure or surgery
HIGH Bleeding Risk:
Prophylactic dose of LMWH, UFH or fondaparinux minimum 6 h after invasive procedure or surgery if venous thromboprophylaxis is indicated
Therapeutic dose of DOACs when hemostasis is controlled (24-72 h)
For neuraxial anesthesia with indwelling catheter:
Resumption with LMWH or UFH until indwelling catheter is out
Heidbuchel et al. Preoperative interruption
No bridging
CrCl ≥80 ml/min ≥ 24 h ≥ 48 h ≥ 24 h ≥ 48 h ≥ 24 h ≥ 48 h
CrCl 50–80 ml/min ≥ 36 h ≥ 72 h ≥ 24 h ≥ 48 h ≥ 24 h ≥ 48 h
CrCl 30–50 ml/min ≥ 48 h ≥ 96 h ≥ 24 h ≥ 48 h ≥ 24 h ≥ 48 h
CrCl 15–30 ml/min Not indicated Not indicated ≥ 36 h ≥ 48 h ≥ 36 h ≥ 48 h
CrCl <15 ml/min No official indication for use
Resumption after invasive procedure or surgery   LOW Bleeding Risk:
• DOACs 6-8 h
HIGH Bleeding Risk:
• Low TE risk ➔ resume DOACs 48-72 h after procedure
• High TE risk ➔ prophylactic or intermediate dose of LMWH 6-8 h after procedure, resume DOACs when hemostasis is controlled (48-72 h)
Spyropoulos et al. Preoperative interruption
No bridging
CrCl >50 mL/min Last dose 2 days before surgery Last dose 3 days before surgery Last dose 2 days before surgery Last dose 3 days before surgery Last dose 2 days before surgery Last dose 3 days before surgery
CrCl 30–50 mL/min Last dose 3 days before surgery Last dose 4–5 days before surgery Last dose 2 days before surgery Last dose 3 days before surgery   
CrCl 15–29 mL/min    Depends on patient and procedural factors Depends on patient and procedural factors   
Resumption after invasive procedure or surgery   LOW Bleeding Risk:
• DOACs 24 h
HIGH Bleeding Risk:
• Low TE risk ➔ resume DOACs 48-72 h after procedure
• High TE risk ➔ consider a reduced dose of dabigatran (75 mg twice daily), rivaroxaban (10 mg once daily) or apixaban (2,5 mg twice daily) on the evening after surgery and on the following day (first postoperative day) after surgery.
  1. CrCl: creatinine clearance, LMWH: low molecular weight heparin, UFH: unfractionated heparin, TE: thrombo-embolic