Direct oral anticoagulants (DOACs), apixaban, rivaroxaban, edoxaban, and dabigatran, have revolutionized anticoagulation therapy due to their efficacy, convenience, and safety profile compared to warfarin. However, their use presents unique challenges when patients undergo surgical or nonsurgical procedures. An estimated 20% of patients on DOACs face this situation annually.

In 2024, JAMA published an authoritative review offering standardized strategies for managing DOACs in the perioperative setting, reducing both bleeding and thromboembolism risks. 

Why perioperative DOAC management matters

Surgical procedures in anticoagulated patients risk two major outcomes:

• Excessive bleeding during or after the procedure
• Thromboembolism from prematurely stopping anticoagulation

DOACs, due to their rapid onset and offset, allow flexibility in perioperative planning. Their short half-lives (8–14 hours) and predictable pharmacokinetics eliminate the need for routine bridging with low-molecular-weight heparin (LMWH), simplifying perioperative care.

Classification of procedure-related bleeding risk

1. Minimal risk

Examples:

• Dental cleaning, single tooth extraction
• Skin biopsy, minor dermatologic procedures
• Cataract surgery

Recommendation:

• DOACs can generally be continued
• Omit morning dose (for BID regimens) or delay evening dose (for QD regimens)

2. Low to moderate risk

Examples:

• Colonoscopy (without large polypectomy)
• Laparoscopic cholecystectomy
• Hernia repair

Recommendation:

• Withhold DOAC 1 day before surgery
• Resume DOAC 24 hours post-procedure
  

3. High risk

Examples:

• Major orthopedic surgery (hip/knee replacement)
• Cancer resection, cardiac surgery
• Procedures involving the brain or spine

Recommendation:

• Withhold DOAC 2 days before surgery
• Resume DOAC 48–72 hours after, depending on bleeding and hemostasis

DOAC pharmacology and adjustment factors

• Apixaban, rivaroxaban, edoxaban: Factor Xa inhibitors
• Dabigatran: Direct thrombin inhibitor (Factor IIa)

Renal clearance:

Dabigatran: ~80%
Edoxaban: ~50%
Apixaban: ~25%
Rivaroxaban: ~33%

Dosing modifications required in:

• CrCl < 50 mL/min
• Age ≥ 80 years
• Body weight ≤ 60 kg
• Concomitant P-gp or CYP3A4 modulators

Reversal agents:

• Dabigatran: Idarucizumab
• Xa inhibitors: Andexanet alfa, prothrombin complex concentrates (PCCs)

Step-by-step perioperative management

Preoperative DOAC interruption

1. Identify DOAC and the patient’s renal function
2. Assess procedural bleeding risk
3. Plan interruption interval:
   • Minimal risk: No interruption or skip one dose
   • Low-moderate risk: Hold DOAC 1 day prior
   • High risk: Hold DOAC 2 days prior (extend for impaired renal function)
4. Avoid bridging with heparin due to increased bleeding risk

Postoperative DOAC resumption

1. Confirm surgical hemostasis
2. Resume DOAC:
   • 24 hrs after a low/moderate risk procedure
   • 48–72 hrs after high-risk procedure
3. If oral meds can’t be resumed (e.g., bowel surgery), use prophylactic-dose LMWH until safe

Adjusting for renal function: When to stop DOACs

Kidney function significantly affects DOAC elimination, especially for dabigatran, which is ~80% renally cleared. Use the following timing adjustments based on creatinine clearance (CrCl):

Special note: neuraxial anesthesia and DOACs

Patients undergoing spinal or epidural anesthesia (neuraxial procedures) require extended DOAC interruption to reduce the rare but serious risk of spinal hematoma and paralysis.

Conclusion

With proper risk stratification and standardized protocols, perioperative management of DOACs can be safe, efficient, and free of unnecessary testing or bridging. The key is individualized care based on bleeding risk, renal function, and procedural timing. Implementing evidence-based strategies minimizes patient risk and improves surgical outcomes.

Reference: Douketis JD, et al. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA. 2024;332:825-834.

Read more about this topic in NYSORA’s Anesthesia Updates.