Perioperative management of direct oral anticoagulants requires individualized strategies based on procedural bleeding risk, patient renal function, and specific laboratory testing.
What is the optimal perioperative management strategy for patients on direct oral anticoagulants undergoing invasive procedures?
This review provides a systematic approach to perioperative DOAC management, emphasizing the risks of heparin bridging and the utility of laboratory testing and antidotes.
Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.
Dubois et al. (Mon,) conducted a review in Patients on direct oral anticoagulants requiring invasive procedures. Perioperative management of direct oral anticoagulants was evaluated. Perioperative management of direct oral anticoagulants requires individualized strategies based on procedural bleeding risk, patient renal function, and specific laboratory testing.