How to manage direct oral anticoagulants (DOACs) around surgery?!

As a clinical pharmacist, you'll face questions about how to manage direct oral anticoagulants (Eliquis, etc) around an elective procedure or surgery. Direct oral anticoagulants (DOACs) kick in and wear off faster than warfarin, so they need to be managed differently around procedures.

Explain it's okay to continue DOACs for many low-bleeding-risk procedures, such as cataract surgery, tooth extraction (dental), or skin biopsy. But in these cases, recommend delaying the DOAC the day of surgery until about 4 to 6 hours after the procedure. This may mean skipping the morning dose altogether if the DOAC is dosed BID.

On the other hand, generally advise holding the DOAC 1 day before other low-bleeding-risk procedures, such as colonoscopy or upper endoscopy since these may involve biopsy or polyp removal. Suggest holding 2 days before procedures with high bleeding risk, such as major abdominal, orthopedic, or vascular surgery. But also consider renal function. For example, suggest holding for 3 days prior if CrCl is below 30 mL/min or up to 5 days with dabigatran (Pradaxa), which relies on renal clearance more than other DOACs.

Typically suggest restarting DOACs 1 day after a low-bleeding-risk procedure or 2 to 3 days after other procedures or surgery. Don't recommend "bridging" with an injectable anticoagulant (enoxaparin [Clexane], etc) when a DOAC is held, since DOACs work quickly. Plus studies with warfarin suggest bridging often does more harm than good. Expect elective procedures to be delayed if clot risk is high, such as patients with a venous thromboembolism within the past 3 months.

References

• Douketis, J.D., Spyropoulos, and others (2019). Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant. JAMA Internal Medicine. [online] Available at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740207

  Doherty, J.U., Gluckman, T.J., Hucker, W.J., Januzzi, J.L., Ortel, T.L., Saxonhouse, S.J. and Spinler, S.A. (2017). 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. Journal of the American College of Cardiology, [online] 69(7), pp.871–898. Available at: http://www.onlinejacc.org/content/early/2017/01/05/j.jacc.2016.11.024