Perioperative Management of DOACs
Problem:
 ✖ Each year approximately 250,000 patients on chronic anticoagulation in North America require an invasive or surgical procedure.
 ✖ For patients on warfarin, this requires an extended interruption for at least 5 days.
 ✖ For patients taking direct acting oral anticoagulants (DOACs) the interruption period is shorter. However, there is no commonly available lab test to assess for anticoagulant effect prior to surgery.
Solution:
 ✔ Use recent creatinine clearance (calculated using actual body weight) to determine timing of DOAC interruption per treatment table.
 ✔ Assess patient-specific and procedural bleeding risk
 ✔ Procedures with a very low bleeding risk may not require anticoagulation interruption.
Discontinuation of Therapy
 • Dabigatran (direct thrombin inhibitor)
 • Apixaban, Edoxaban, Rivaroxaban (anti-XA inhibitor)
Resumption of Therapy
 • Low Bleed-Risk Surgery: 24 hours postoperative
 • High Bleed-Risk Surgery: 48-72 hours postoperative

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