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Guide Peri-Op Management of Direct Oral Anticoagulants

front 1

How to manage DOACS around surgery?

back 1

  • Holding
  • Bridging
  • Reversing

front 2

Holding DOACS BEFORE surgery

back 2

  • Hold x 1 day before for low bleeding risk: colonoscopy or upper endoscopy
  • Hold x 2 days before for high bleeding risk: abdominal or vascular surgery

front 3

Holding DOACS AFTER surgery

back 3

  • Restart DOACS 1 day after low bleeding risk
  • Restart DOACS 2 -3 days after high bleeding risk

front 4

Holding DOACS in pts with decreased renal function

back 4

  • If CrCl < 50, Hold Pradaxa for 2 days before low bleeding risk
  • Hold Pradaxa for 4 days before high bleeding risk

front 5

DOACs with minimal bleeding risk...such as tooth extraction or skin biopsy

back 5

  • Delay DOACs until 4-6 hours post-op. This means skipping the morning dose of twice daily DOACs

front 6

What is bridging?

back 6

  • Dont routinely recommend bridging with injectable anticoagulant (Loveno) while DOACs is held

front 7

Reversal agent for factor Xa inhibitors

back 7

  • Andexxa >< Apixaban (Eliquis) or Rivaroxaban (Xarelto)
  • 4 factor prothromnin complex concentrate: Kcentra
  • Idarucizumab (Praxbind) >< Dabigatran

front 8

OPTIMIZE ANTICOAGULATION FOR PATIENTS WITH A-FIB

back 8

OPTIMIZE ANTICOAGULATION FOR PATIENTS WITH A-FIB

front 9

Scores to identify risk factors for A.FIB

back 9

  • CHADS-VASC scores
  • Age, sex, gender, Stroke/ thrombo history, HTN, Vascular disease (prior stroke, MI), diabetes history, CHF history

front 10

Anticoagulation in Afib pts?

back 10

  • Provide a net benefit for most pt with Afib + non-sex risk factor
  • DOACs preferred over Warfarin due to non INR monitoring & less intracranial bleeding

front 11

What kind of DOACS to choose?

back 11

  • Lean toward Eliquis due to less significant bleeding
  • BEER criteria states avoid Pradaxa and Xalrelto in elderly

front 12

Pts to avoid DOACs and rely on warfarin?

back 12

  • Avoid in pts with mechanical heart valve and
  • Moderate to severe midtral stenosis
  • Non-adherence pts: DOACS may increase clot risk if miss doses >< warfarin much longer acting and maybe forgiving

front 13

Meds to avoid DOACS

back 13

  • Rifampin or Carbamazepine...lower DOAC level and increase clot risk

=> Recommend warfarin instead with close monitoring

front 14

Ways to limit bleeding risk?

back 14

  • Adjust DOACS in pt with kidney function
  • Manage high BP
  • and reevaluate NSAIDs and aspirin

front 15

Aspirin in A.fib pts?

back 15

  • Not really recommend it, even in lower-risk patients
  • Antiplatelets are not as effective...and may not have lower bleeding risk