Guidelines for the Peri-operative Management of Direct Oral Anticoagulants (DOACs) for patients undergoing elective procedures

1. Aims
2. Objectives
3. Scope
4. Exclusions
5. Background
6. Stopping anticoagulation therapy pre-operatively
7. Assessing the risk of post operative bleeding
8. Restarting anticoagulation after surgery

1. Aims

This guideline discusses the perioperative management of patients taking apixaban, dabigatran, edoxaban and rivaroxaban (direct oral anticoagulants (DOACs) previously called NOACs) and when these should be stopped prior to elective procedures.

2. Objectives

To provide evidence-based recommendations for the management of perioperative anticoagulation.

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3. Scope

This guideline applies to adult patients requiring interruption to their oral anti-coagulation prior to elective procedures.

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4. Exclusions

• Emergency surgery

Emergency surgery in anticoagulated patients should be discussed urgently with the on call haematology team. Contact via switchboard.

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5. Background

Peri-operative management of patients taking oral anticoagulants must balance the risk of thrombosis associated with the interruption of anticoagulation and the risk of haemorrhage associated with the procedure and the recommencement of anticoagulation.  Both may be associated with significant morbidity and mortality risks.

The direct oral anticoagulants (DOACs) are an alternative for vitamin K antagonists (VKAs) used in the management of VTE (venous thromboembolism) or the prevention of stroke in patients with non-valvular atrial fibrillation (AF).

The aim of interrupting anticoagulation therapy peri-operatively is to minimise the anticoagulant effect at the time of the procedure. The DOACs rarely require bridging therapy as they are shorter acting than VKAs and therefore can be ceased later i.e., closer to the date of the procedure.

Apixaban, dabigatran, edoxaban and rivaroxaban differ in their half-lives (which are elevated by worsening renal function) and thus have different advice about the cessation of the medication prior to procedures.

The advice on stopping the DOACs prior to procedures is summarised in table 1 below ^2,3,4:

To note: DOACs have variable effects on coagulation screens and an INR of 1 in a patient on a DOAC does not mean they are not anticoagulated.

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6. Stopping anticoagulation therapy pre-operatively

• Minor surgery that does not require interruption of anticoagulation

For many minor surgical procedures (e.g. minor dermatological surgery, minor dental surgery, cataract surgery), where there is a very low bleeding risk and warfarin would be continued with a therapeutic INR, no interruption of anticoagulation is required. It may be pertinent for procedures done within 4 hours of a dose of oral anticoagulant for the dose to be withheld until haemostasis is achieved after the procedure. (i.e. a morning dose of rivaroxaban normally taken at 8am could be delayed until midday for a procedure timed at 10am) If in doubt contact the surgeon to confirm.

• Bridging with LMWH

Please note that temporary withholding of DOACs prior to surgery does not require bridging with therapeutic LWMH in the interim. If a patient has a high thrombotic risk (recent stroke or VTE within 3 months) and the surgical team feel an alternative plan is needed, this will need discussing with the haematology and thrombosis team. Please contact haematology directly with sufficient notice prior to elective patients' date of surgery. A dose of prophylactic LMWH can be given a minimum of 12 hours prior to surgery if necessary. 

Table 1. Suggested guide for pre-operative management for patients taking DOACs ^2,3

*Please note that pre-operative cessation of low dose rivaroxaban (2.5mg twice daily) has not been studied. An LTHT approach for vascular and cardiology indications is to follow the dosing information for once daily rivaroxaban. This differs from the Rivaroxaban 2.5mg SPC5.  If there are concerns about the thrombotic risk of a patient on low dose rivaroxaban then please discuss with the cardiologist or vascular surgeon. An MDT approach will be needed with the surgeon to assess the bleed risk of the procedure.

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7. Assessing the risk of post operative bleeding

The administration of antithrombotic therapy in the perioperative period should consider the risk of bleeding associated with the surgery or procedure.

The risk of perioperative bleeding is based on the risk of bleeding associated with the surgery or procedure combined with an assessment of postoperative haemostasis.

Account should be taken of the combined risk of bleeding from surgery and the administration of anticoagulation.

After procedures associated with a high risk of bleeding, post-operative anticoagulation therapy should be administered with caution, and deferring therapeutic anticoagulation is usually the safer option.

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8. Restarting anticoagulation after surgery

Oral intake should have been re-established before restarting anticoagulation. If the bleeding risk is low and adequate haemostasis is secured, DOAC therapy can be resumed at the usual dose on the day following surgery/procedure. It must be remembered that the peak of anticoagulant activity after a dose of any of the DOACs is 1-3 hours.

In cases where patients are at higher risk of bleeding and high risk of thrombosis, VTE prophylaxis with low molecular weight heparin (LMWH) can be prescribed if safe to do so then DOAC therapy may be reintroduced 48-72 hours post-operatively (and LMWH stopped). In the case of complicated patients, or if haemostasis is not adequately secured, haematology should be contacted for advice.