Updated guidelines suggest interrupting DOAs the night before low bleeding risk procedures, and 3-5 days before high bleeding risk procedures depending on the drug and renal function, without routine bridging.
How should direct oral anticoagulants be managed in patients undergoing elective surgeries and invasive procedures?
Updated French guidelines provide specific timing for perioperative interruption of direct oral anticoagulants based on procedural bleeding risk and renal function, advising against routine bridging.
Since 2011, data on patients exposed to direct oral anticoagulants (DOAs) while undergoing invasive procedures have accumulated. At the same time, an increased hemorrhagic risk during perioperative bridging anticoagulation without thrombotic risk reduction has been demonstrated. This has led the GIHP to update their guidelines published in 2011. For scheduled procedures at low bleeding risk, it is suggested that patients interrupt DOAs the night before irrespective of type of drug and to resume therapy six hours or more after the end of the invasive procedure. For invasive procedures at high bleeding risk, it is suggested to interrupt rivaroxaban, apixaban and edoxaban three days before. Dabigatran should be interrupted according to the renal function, four days and five days if creatinine clearance is higher than 50mL/min and between 30 and 50mL/min, respectively. For invasive procedures at very high bleeding risk such as intracranial neurosurgery or neuraxial anesthesia, longer interruption times are suggested. Finally, bridging with parenteral anticoagulation and measurement of DOA concentrations can no longer routinely be used.
Albaladejo et al. (Tue,) conducted a review in Patients on direct oral anticoagulants undergoing elective surgeries and invasive procedures. Perioperative management of direct oral anticoagulants was evaluated. Updated guidelines suggest interrupting DOAs the night before low bleeding risk procedures, and 3-5 days before high bleeding risk procedures depending on the drug and renal function, without routine bridging.