Bleeding risk should dictate strategy for managing patients on direct oral anticoagulants

Editor's Note

Clinicians managing surgical patients on direct oral anticoagulants (DOACs) should adopt a different approach depending on the procedure, according to research published August 12 in JAMA Network.

Used to treat patients with atrial fibrillation and venous thromboembolism, DOACs must be managed effectively to minimize risks of bleeding, researchers write. For elective procedures, they recommend a standardized approach based on the bleeding risk:

• Procedures with minimal bleeding risk may allow continuation of DOACs, or temporary discontinuation on the day of the procedure if there's concern about excessive bleeding.
• For low to moderate risk procedures, DOACs should be discontinued 1 day before surgery and resumed 1 day after.
• For high-risk procedures, DOAC use should stop 2 days before and restart 2 days after the procedure.

This approach has been shown to result in low rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%), researchers write.

In cases where patients need emergent or urgent surgery, bleeding rates can rise to 23%, with thromboembolism reaching 11%. In such scenarios, laboratory testing to measure preoperative DOAC levels can help determine the need for reversal agents, such as prothrombin complex concentrates or idarucizumab, before proceeding with the surgery.

“When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging,” researchers conclude. “When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.”