Perioperative management of patients on direct oral anticoagulants

Dubois, Virginie; Dincq, Anne-Sophie; Douxfils, Jonathan; Ickx, Brigitte; Samama, Charles-Marc; Dogné, Jean-Michel; Gourdin, Maximilien; Chatelain, Bernard; Mullier,  François; Lessire, Sarah

doi:10.1186/s12959-017-0137-1

Thrombosis Journal

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 ≥ 24 h before surgery	Last dose 5 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
		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.

CrCl: creatinine clearance, LMWH: low molecular weight heparin, UFH: unfractionated heparin, TE: thrombo-embolic

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