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