[Management of direct oral anticoagulants for invasive procedures]

Area of Science:

• Pharmacology
• Clinical Medicine
• Thrombosis Management

Context:

• Direct Oral Anticoagulants (DOACs) including rivaroxaban, apixaban, and dabigatran etexilate are widely used.
• Managing bleeding risk associated with DOACs during medical procedures presents a clinical challenge.
• Current guidelines offer varying recommendations for managing DOACs around surgical interventions.

Purpose:

• To outline strategies for managing Direct Oral Anticoagulants (DOACs) in patients undergoing elective and urgent procedures.
• To provide guidance on the timing of DOAC cessation and the potential use of bridging therapy.
• To discuss the utility of measuring DOAC plasma concentrations in urgent situations and managing massive bleeding.

Summary:

• For elective procedures with high bleeding risk, stopping DOACs five days prior ensures elimination; heparin bridging is reserved for high thrombotic risk patients.
• For elective procedures with low bleeding risk, omitting the night-before DOAC dose is recommended.
• In urgent high-bleeding risk scenarios, DOAC levels guide management ( <30 ng/mL permits procedures; >400 ng/mL indicates high risk).
• No approved antidote exists for DOAC-induced bleeding; prothrombin concentrates may be considered.

Impact:

• Provides clinicians with practical guidance for optimizing patient safety during procedures while on DOAC therapy.
• Aims to reduce the incidence of DOAC-related bleeding complications and thrombotic events.
• Facilitates informed decision-making regarding DOAC management in diverse clinical settings.