Management of direct oral anticoagulants in patients undergoing elective surgeries and invasive procedures: Updated guidelines from the French Working Group on Perioperative Hemostasis (GIHP) – September 2015

Abstract

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.

Perioperative management of patients on direct oral anticoagulants

“…Patients with chronic AF have twice the risk of postoperative stroke than patients without AF [31]. Currently, these scores are proposed to identify patients with AF at high TE risk in a perioperative setting, when they have more than 4 individual risk factors for stroke [19, 32, 33]. However, only the individual risk factors from the CHADS2 stroke risk index were assessed in stratifying the risk of postoperative stroke and not the global value of both scores.…”

“…procedures with minimal risk), as for example superficial skin surgeries, parietal surgery, cataract surgery, and minor dental procedures [47]. It is suggested that the morning dose of anticoagulant should be omitted on the day of the procedure to avoid peak concentrations during the procedures [19]. …”

“…Due to the variability in DOAC metabolism and elimination, this interval corresponds to 4–5 days for dabigatran, and 3 days for rivaroxaban and apixaban [57, 63]. Similarly in a very cautious approach, the GIHP proposed 5 days of DOAC interruption before neuraxial anesthesia [19]. …”

“…The use of UFH requires hospitalization to monitor the anticoagulant level, but it has the advantage of being eliminated independently of the patient’s renal function [81]. Indeed, a recent survey demonstrated that despite the evidence that bridging with heparin should be greatly reduced in clinical practice and reserved for particularly high TE settings, many physicians involved in perioperative management still continue to bridge patients with heparin at DOAC arrest without a standardized protocol [19, 33, 45, 46]. …”

“…More recently, sub-group analyses of the phase III trials as well as results of recent clinical studies [15, 16] have influenced further guidelines [17–19]. Nowadays, around 10–15% of patients on DOACs will have to interrupt their anticoagulant before an invasive procedure every year [20, 21].…”