Direct oral anticoagulants

We recommend assessment of creatinine clearance in patients receiving direct oral anticoagulants (DOACs) who are scheduled for surgery. 1B

We suggest that DOACs should only be withheld the day before surgery for patients undergoing low bleeding risk procedures such as skin surgery, dental and oral procedures, gastric and colonic endoscopies (even if biopsy is scheduled, but no polypectomies) and most ophthalmological surgery. 2C

For intermediate and high bleeding risk procedures

  1. we recommend that rivaroxaban, apixaban and edoxaban should not be given for 2 days before the procedure (i.e. last oral intake 3 days before), pending a creatinine clearance (Cockcroft–Gault formula) above 30 ml min-1. No bridging therapy is needed. 1C
  2. we recommend that dabigatran should not be given for 3 days before the procedure (i.e. last oral intake 4 days before), if the creatinine clearance is above 50 ml min-1 and 4 days before the procedure (i.e. last oral intake 5 days before), if the creatinine clearance is between 30 and 50 ml min-1. No bridging therapy is needed. 1C
We suggest that in severe bleeding patients treated with dabigatran, a specific antidote (idarucizumab) should be considered. 2C

We suggest that for low bleeding risk procedures, when haemostasis is achieved, DOACs should be recommenced during the evening after the procedure (at least 6 h after). 2C

We suggest that for intermediate and high bleeding risk procedures, prophylactic doses of LMWH or DOACs (according to specific indications) should be given postoperatively whenever VTE prophylaxis is requested and then the full therapeutic dose of DOAC should be resumed up to 72 h postoperatively, when surgical haemostasis is achieved. 2C