How to manage DOACS around surgery?

• Holding
• Bridging
• Reversing

Holding DOACS BEFORE surgery

• 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

Holding DOACS AFTER surgery

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

Holding DOACS in pts with decreased renal function

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

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

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

What is bridging?

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

Reversal agent for factor Xa inhibitors

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

OPTIMIZE ANTICOAGULATION FOR PATIENTS WITH A-FIB

OPTIMIZE ANTICOAGULATION FOR PATIENTS WITH A-FIB

Scores to identify risk factors for A.FIB

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

Anticoagulation in Afib pts?

• 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

What kind of DOACS to choose?

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

Pts to avoid DOACs and rely on warfarin?

• 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

Meds to avoid DOACS

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

=> Recommend warfarin instead with close monitoring

Ways to limit bleeding risk?

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

Aspirin in A.fib pts?

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