Approach to the new oral anticoagulants in family practice: Part 2: addressing frequently asked questions

Article Figures & Data

Table 1.

Suggested preoperative management of patients taking NOACs

DRUG (DOSE REGIMEN)	RENAL FUNCTION	MINOR SURGERY OR PROCEDURE (LOW BLEEDING RISK)	MAJOR SURGERY OR PROCEDURE OR SPINAL ANESTHESIA (HIGH BLEEDING RISK)
Dabigatran (twice daily)
• Half-life = 14 h	Normal renal function or mild impairment (eGFR > 50 mL/min)	Last dose: 2 d before surgery (skip 2 doses)	Last dose: 3 d before surgery (skip 4 doses)
• Half-life = 15–18 h	Moderate renal impairment (eGFR 30–50 mL/min)	Last dose: 3 d before surgery (skip 4 doses)	Last dose: 4–5 d before surgery (skip 6–8 doses)
Rivaroxaban (once daily)
• Half-life = 9 h	Normal renal function or mild to moderate impairment (eGFR > 30 mL/min)	Last dose: 2 d before surgery (skip 1 dose)	Last dose: 3 d before surgery (skip 2 doses)
Apixaban (twice daily)
• Half-life = 9 h	Normal renal function or mild to moderate impairment (eGFR > 30 mL/min)	Last dose: 2 d before surgery (skip 1 dose)	Last dose: 3 d before surgery (skip 4 doses)

Table 2.

Suggested postoperative management of patients receiving NOACs

NOAC	MINOR SURGERY OR PROCEDURE (LOW BLEEDING RISK)	MAJOR SURGERY OR PROCEDURE OR SPINAL ANESTHESIA (HIGH BLEEDING RISK)^*
Dabigatran	Resume 1 d after surgery (24 h postoperative), 150 (or 110) mg twice daily	Resume 2 d after surgery (48 h postoperative), 150 (or 110) mg twice daily
Rivaroxaban	Resume 1 d after surgery (24 h postoperative), 20 mg once daily	Resume 2 d after surgery (48 h postoperative), 20 mg once daily
Apixaban	Resume 1 d after surgery (24 h postoperative), 5 mg twice daily	Resume 2 days after surgery (48 h postoperative), 5 mg twice daily

NOAC—new oral anticoagulant.
↵* An alternative approach would be to give a reduced dose of an NOAC for the initial 1–3 d. For example, dabigatran, 75 mg twice daily; rivaroxaban, 10 mg daily; or apixaban, 2.5 mg twice daily.
Data from Douketis²² and Thrombosis Canada.²⁴