1. Low Procedural Bleed Risk
Guidelines for the Peri-Procedural Management of Adults Taking Target Specific Anticoagulants (TSOACs): dabigatran, rivaroxaban, apixaban, edoxaban
Drug
Renal Function
Low Procedural Bleed Risk
(~2-3 half-lives between last dose & procedure)
High Procedural Bleed Risk
(~4-5 half-lives between last dose & procedure)
Very High Procedural Bleed Risk
(e.g., neuraxial, cardiothoracic, intracranial, spine)
Resumption of TSOAC
Low bleed risk procedures
High / Very High bleed risk procedures
Dabigatran
(Pradaxa®)
75mg, 150mg BID
CrCl > 50
mL/min
t½=14-17h
Interval between last dose and procedure: 48 hrs
Last dose: 3 days prior
Interval between last dose and procedure: 96 hrs
Last dose: 5 days prior
Interval between last dose and procedure: 120 hrs
Last dose: 6 days prior
May resume 24 hrs postop
Very high thromboembolism risk:Resume no sooner than
48-72 hrs postop
Low/Int thromboembolism risk: resume no sooner than POD #5-7
Always discuss timing of resumption with proceduralist
For neuraxial anesthesia:
first dose no sooner than 6 hrs after catheter removal. See Neuraxial guidelines for details.
Confirm that pre-op PTT or thrombin time is normal
CrCl mL/min
t½=16-18h
Interval between last dose and procedure: 60 hrs
Interval between last dose and procedure: ≥ 96 hrs
Last dose: ≥5 days prior
Interval between last dose and procedure: >120 hrs
Last dose: ≥ 6 days prior
Rivaroxaban
(Xarelto®)
15mg daily-BID, 20mg daily
CrCl > 30
t½=8-9h
Interval between last dose and procedure: 24 hrs
Last dose: 2 days prior
Interval between last dose and procedure: 72 hrs
Last dose: 4 days prior
CrCl mL/min
t½=9-10h
Apixaban
(Eliquis®)
2.5mg, 5mg, 10mg BID
t½=7-8h
t½=17-18h
Interval between last dose and procedure: 120 hrs
Edoxaban
(Savaysa®)
30mg, 60mg daily
CrCl > 50 mL/min
t½=9-14h
Interval between last dose and procedure: 36 hrs

2. Don’t Interrupt TSOAC Procedures off anticoagulation
*HEART VALVES: Do not use TSOACS for mechanical heart valves.
Procedures off anticoagulation
Examples
Invasive cardiac procedures (such as heart valve replacement, coronary artery bypass graft)
Neurosurgical /neuraxial procedures
Major surgery with significant tissue injury (such as orthopedic, abdominal)
Certain interventional radiologic or endoscopic procedures with biopsy
Higher risk urologic procedures: TURP, prostate biopsy, lithotripsy, prostatectomy, bladder surgery
Procedures potentially safe on anticoagulation
Endoscopic or urologic procedures without biopsy
Skin biopsy
Potentially bloodless surgery (e.g, cataract).Consider risk of anesthesia administration (e.g., retrobulbar administration)
Simple dental procedures such as cleaning,extractions, endodontics
High Thrombotic Risk
AFIB: CHADS2 5-6, TIA/CVA<3 mo,
VTE: VTE within 3 mo severe thrombophilia (deficiency of protein C, protein S, ATIII, APLA, or multiple abnormalities), recurrent VTE while ON anticoagulation
Interrupt TSOAC
Bridging anticoagulation NOT recommended.
Patients may benefit from expert consultation to help weigh risk of thrombosis vs. bleed.
Don’t Interrupt
TSOAC
Moderate Thrombotic Risk
AFIB: CHADS2 3-4
VTE: VTE within 3-12 mo, recurrent VTE, non-severe thrombophilia (heterozygous factor V Leiden, PT20210 mutation), or active cancer
Expert consultation if complex patient or if there are questions
Low Thrombotic Risk
AFIB: CHADS2 0-2 & no prior TIA/CVA
VTE: VTE > 12 mo with no other risk factors
NOTES: these are general recommendations and not intended to replace clinician judgment.
Individual patient risk profiles, procedure risk, and provider/patient preference may influence recommendations.
See “UCSF Guidelines for the use of antithrombotic agents in the setting of neuraxial procedures” for additional information on neuraxial anesthesia
Clearance of anticoagulant effect depends on renal function--reassess renal function within one month of pre-op planning
Full anticoagulant effect occurs within hours of resuming TSOAC therapy. Patient must be tolerating orals and have good absorption. Post-procedure resumption of anticoagulation should be done with the approval of the proceduralist.
Bridging with parenteral anticoagulants is NOT usually recommended for patients on TSOACs. However, bridging can be considered in patients at VERY high risk of thrombosis or with prolonged TSOAC hold times. Consultation with a specialist is recommended in complex situations. UCSF: Hematology Consult ( ) or Anticoagulation Clinic. SFGH: Anticoagulation Pharmacist ( ). VA: Anticoagulation Service (Refer to on-call schedule)
References
1. Management of Anticoagulants in the Peri-Procedural Period. New York State’s QIO/Centers for Medicare & Medicaid Services document, 2014.
2. American Society of Regional Anesthesia and Pain Medicine, Anticoagulation 3rd Edition Guidelines (2010) and Interim Update
Version 1.0 developed by Margaret Fang, MD, Steven Kayser, PharmD, Tracy Minichiello, MD, Christina S. Wang, PharmD. Approved by UCSF P&T xx.2015