Update on Direct Oral AntiCoagulants (DOACs)

Area of Science:

• Cardiology
• Pharmacology
• Anesthesiology

Background:

• Current recommendations for perioperative management of Direct Oral AntiCoagulants (DOACs) require updating.
• Individual patient characteristics, renal/hepatic function, and surgery-specific bleeding risk influence DOAC interruption duration.
• The risk of neurologic deficits necessitates conservative interruption intervals for neuraxial anesthesia.

Purpose of the Study:

• To provide updated recommendations for the perioperative management of DOACs.
• To clarify the role of bridging therapy and drug interactions.
• To address medication adherence in long-term DOAC use.

Main Methods:

• Review of pharmacokinetic profiles of DOACs.
• Analysis of bleeding and thromboembolic risks associated with different interruption and bridging strategies.
• Evaluation of drug-drug interactions and medication adherence data.

Main Results:

• A preoperative interruption of 24-96 hours is recommended, individualized by patient factors and bleeding risk.
• Preoperative bridging with LMWH should be omitted due to increased bleeding risk without altering thromboembolic risk.
• Postoperative reinstitution of DOACs within 24-72 hours is advised, with LMWH considered for high-risk patients.
• Drug interactions require careful management using specialized resources.
• Long-term DOAC adherence presents challenges, with persistence being a key factor for treatment success.

Conclusions:

• Updated perioperative DOAC management strategies are crucial for patient safety.
• Individualized patient assessment is paramount for determining optimal interruption and resumption timing.
• Addressing drug interactions and improving medication adherence are essential for effective long-term DOAC therapy.