Standardized perioperative management of DOACs with interruption per pharmacokinetic principles resulted in low rates of 30-day postoperative symptomatic VTE (0.09%–0.48%) and major bleeding (0.9%–2.49%) in patients undergoing elective surgery, while perioperative bridging with LMWH increased major bleeding risk fourfold without reducing thromboembolism risk (OR 4.6 for bleeding, OR 1.9 for thromboembolism).
Pharmacogenomics and anti-FXa monitoring may help optimize perioperative DOAC management and personalize dose adjustments in patients undergoing elective colorectal surgery.
Perioperative management of patients on direct oral anticoagulants (DOACs) for preoperative deep vein thrombosis (DVT), pulmonary embolism (PE), or atrial fibrillation (AF), who subsequently undergo elective colorectal surgery, is a frequent clinical scenario with no clear consensus on best practices. Further complicating this issue, venous thromboembolism (VTE) and bleeding rates vary widely, ranging from 4.8% to 12.6% for VTE and 1.1% to 2.4% for bleeding, across different procedures (e.g., abdominoperineal resection, anterior resection, rectopexy, colectomy, and total proctocolectomy), as well as between countries, centers and individual surgeons. Therefore, it is necessary for surgeons to identify strategies to optimize when and how to discontinue and resume anticoagulation. Over the past decade, substantial interpatient variability in DOAC plasma levels has been observed, potentially explaining the frequent incidence of clinically relevant nonmajor bleeding (e.g., anastomotic bleeding and hematochezia) and breakthrough VTE in colorectal surgical patients. Given that pharmacokinetic factors, including genetic variations in metabolizing enzymes and efflux transporters as well as drug plasma levels measured by anti-factor Xa (FXa) activity, are associated with both the efficacy and adverse effects of anticoagulants, genotyping and anti-FXa monitoring could play a valuable role in optimizing perioperative DOAC management or enabling personalized dose adjustments. This scoping review summarizes the current evidence and proposes an integrated, personalized approach for perioperative DOAC management in colorectal surgery, with particular emphasis on procedure-specific risks, pharmacogenomics, and individualized risk prediction.
Mao et al. (Thu,) conducted a review in Patients receiving direct oral anticoagulants undergoing elective colorectal surgery for conditions including colorectal cancer, inflammatory bowel disease, diverticular disease, and other colorectal disorders. Direct Oral Anticoagulants (DOACs) - including apixaban, dabigatran, and rivaroxaban vs. Standardized preoperative DOAC interruption per guideline vs non-standardized management or LMWH bridging vs no bridging was evaluated on 30-day postoperative incidence of symptomatic venous thromboembolism (VTE) and major bleeding. Standardized perioperative management of DOACs with interruption per pharmacokinetic principles resulted in low rates of 30-day postoperative symptomatic VTE (0.09%–0.48%) and major bleeding (0.9%–2.49%) in patients undergoing elective surgery, while perioperative bridging with LMWH increased major bleeding risk fourfold without reducing thromboembolism risk (OR 4.6 for bleeding, OR 1.9 for thromboembolism).
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