Preoperative medication managment

1. Pre-operative medication management

2. • At least 50 percent of patients undergoing surgery take medications on a regular
basis .
• Clinicians often must decide if chronic medications should be continued in the peri-
operative period.

3. Outline
• Principles of medication management.
• Cardiovascular medications, GI agents, pulmonary agents, Endocrine agents.
• Preo-perative managements of patients receiving anticoagulants.

4. PRINCIPLES OF MEDICATION MANAGEMENT
• A complete medication history should be obtained, and all clinicians involved in patient
management (eg, surgeon, anesthesiologist, medical consultants) .
• Medications associated with known medical morbidity if withdrawn abruptly should be continued
in the peri-operative period or tapered if feasible.
• Medications thought to increase the risk of anesthetic or surgical complications and not essential
for the short-term should be held through the perioperative period.

5. Preoperative medication
• Benefit/Risk
• Continue/discontinue.
• Formulations/alternatives

6. CARDIOVASCULAR MEDICATIONS

7. Beta blockers
• Benefit/risk – Beta blockers have a number of potential beneficial effects when taken
perioperatively. Beta blockers reduce :
– ischemia by decreasing myocardial oxygen demand due to increased catecholamine release.
– They may also help prevent or control arrhythmias.
– Patients who take beta blockers chronically for management of angina are at risk of ischemia with
withdrawal of beta blockade.
– Acute withdrawal of a beta blocker pre- or postoperatively can lead to substantial morbidity and even
mortality .
– Withdrawal issues are of less concern when beta blockers are used for hypertension or migraine
prophylaxis.
Potential adverse effects of perioperative beta blockade include bradycardia and hypotension. Nonselective
beta blockers can interact with epinephrine, used for infiltration anesthesia or management of intraoperative
anaphylaxis

8. Beta blockers
• Continue/discontinue
-we recommend that BBx to be continued in the perioperative period and continued
throughout the hospital stay. The dose of the beta blocker should be closely
regulated throughout the perioperative period to maintain the blood pressure and
heart rate (rate-pressure product) below the patient's ischemic threshold.
• Formulations/alternatives – Intravenous forms of beta blockade, such
as metoprolol, propranolol, and labetalol, should be given if the patient cannot
take oral medications . Esmolol is also available to be used intraoperatively or in an
intensive care unit (ICU) but cannot be administered on a regular hospital floor. We
have a slight preference for beta 1 cardioselective beta blockers, since they are
less likely to cause adverse pulmonary and peripheral vascular effects and may be
associated with a lower risk of postoperative stroke.

9. Calcium channel blockers
Benefit/risk –
• A meta-analysis found that use of calcium channel blockers was
associated with reduced ischemia and atrial arrhythmia in patients
undergoing non-cardiac surgery .
• There are no serious interactions between calcium channel blockers and
anesthetic agents .
• A withdrawal syndrome is not typical, although abrupt discontinuation of
these drugs has been reported to cause severe vasospasm in patients
undergoing coronary revascularization.

10. • Continue/discontinue – we recommend that calcium channel blockers be continued in patients
who are already taking them preoperatively .
• Formulations/alternatives – Intravenous diltiazem is available for patients who are unable to
tolerate oral agents. Short-acting calcium channel blockers are available (diltiazem, verapamil) and
can be substituted with appropriate dosing interval adjustments. Short-acting nifedipine should be
avoided, because it can cause rapid decreases in blood pressure. Amlodipine has a long washout
period, and short-acting substitutes may not be necessary.

11. ACE inhibitors and angiotensin II receptor blockers
• Benefit/risk – The management of patients taking (ACE) /(ARBs)
preoperatively is controversial. ACE inhibitors and ARBs can theoretically blunt
the compensatory activation of the renin-angiotensin system during surgery and
result in prolonged hypotension.
• most studies indicating some increased risk for peri- and postoperative
hypotensive episodes but variable adverse effect on cardiovascular outcomes or
respiratory outcomes when the medications are continued.

12. • Representative studies of outcomes involving noncardiac surgery include
the following:
– patients on ACE inhibitors undergoing noncardiac (mainly orthopedic and
spine) surgery, those who omitted their last preoperative ACE inhibitor dose
were compared with those who continued the medication uninterrupted .
Intraoperative and postoperative hypotension occurred less frequently in the
group who omitted the last dose, but postoperative hypertensive events were
more frequent.
– withholding the ACE inhibitor/ARB 24 hours before noncardiac surgery was
associated with a reduction in composite 30-day all-cause death, stroke, or
myocardial injury and intraoperative hypotension. Withholding perioperative
ACE inhibitor/ARB was not associated with risk of myocardial infarction or
postoperative hypotension.
– In an observational study of over 12,000 patients on chronic diuretic therapy
undergoing noncardiac surgery, ACE inhibitor/ARB treatment was associated
with more frequent episodes of hypotension . However, there were no
differences in the rates of postoperative myocardial infarction or renal failure
between the two groups.
– In a propensity match study of 18,000 patients undergoing noncardiac surgery,
no association was found between continued use of ACE inhibitors and
intraoperative or postoperative upper-airway complications . Furthermore,
uninterrupted perioperative ACE inhibitor use was not associated with in-
hospital complications or increased 30-day mortality.

13. Additional studies have evaluated the effect of
ACE inhibitor therapy in patients undergoing
coronary artery bypass graft (CABG) surgery:
•A trial randomly assigned 40 patients with good left ventricular function who
were undergoing CABG surgery to continue or omit ACE inhibitors before
surgery . Patients who omitted their ACE inhibitors required less vasopressors
during surgery but required more vasodilators to control hypertension in the
early postoperative period.
•A randomized trial of 47 patients on ramipril undergoing CABG on
cardiopulmonary bypass (CPB) found that ACE inhibitor therapy predisposed
to hypotension upon induction and in the post-CPB period, but prophylactic
low-dose vasopressin infusion prevented post-CPB hypotension .
•Nonrandomized studies suggest a possible myocardial protective effect of ACE
inhibitors in patients undergoing CABG surgery .
•Reports conflict on the effect of ACE inhibitors on the risk of acute kidney injury
(AKI) .

14. • Continue/discontinue:
• patients, we usually withhold them on the morning of surgery. However,
when the indication is for heart failure or poorly controlled hypertension,
we continue them to avoid further exacerbation of these conditions. Many
anesthesiologists may prefer to withhold these medications on the
morning of surgery based on concerns about possible hypotension, and in
such cases when we favor continuation, we inform the anesthesiologist of
our justification.
• We recommend resuming these agents as soon as possible
postoperatively, as failure to restart ARBs within 48 hours after surgery has
been associated with increased 30-day mortality
• Formulations/alternatives – Enalapril is available for
short-term intermittent intravenous administration, although
it is used infrequently.

15. Diuretics
• ●Benefit/risk – The two major physiologic effects of concern of loop and thiazide-type diuretics:
• Hypokalemia can theoretically increase the risk of perioperative arrhythmia, although observational studies of
patients with structural heart disease have failed to find such a relationship . Additionally, hypokalemia might
potentiate the effects of muscle relaxants used during anesthesia, as well as provoke paralytic ileus.
• Systemic vasodilatation induced by anesthetic agents may cause hypotension in patients who are intravascularly
depleted from diuretics. However, in a study of elective, noncardiac surgeries in patients chronically treated
with furosemide, the administration of furosemide on the day of surgery did not significantly increase the risk
for intraoperative hypotension

16. • Continue/discontinue
• We advise patients who are taking diuretics for
hypertension to hold the medication on the
morning of surgery.
For patients receiving diuretic therapy to treat heart
failure, diuretic continuation is based upon
assessment of volume status
• If diuretics are held the morning of surgery and
volume overload develops, a quick diuresis can
be initiated by intravenous administration
perioperatively. For patients who require
perioperative diuretics, clinicians should pay close
attention to potassium replacement.
• ●Formulations/alternatives – Intravenous
preparations of loop diuretics are available.

17. • Digoxin
• ●Benefit/risk – Studies on digoxin in the perioperative period are
limited. A subgroup analysis of patients undergoing intrathoracic
surgery found that digoxin decreased the incidence of
postoperative supraventricular arrhythmias .
• ●Continue/discontinue – We recommend
continuing digoxin perioperatively. Obtaining a drug level
preoperatively is not usually required.
• ●Formulations/alternatives – Intravenous digoxin is available if
needed.
• Statins— Evidence has become convincing that HMG CoA
reductase inhibitors (statins) may prevent vascular events in the
perioperative period. We recommend continuing statins throughout
the perioperative period.

18. GASTROINTESTINAL AGENTS

19. H2 blockers and proton pump inhibitors
Benefit/risk –
• stress-related mucosal damage, may be minimized by administration of these
drugs.
• Both H2 blockers and proton pump inhibitors decrease gastric volume and raise
gastric fluid pH, thereby reducing the risk of chemical pneumonitis from aspiration
• Rare central nervous system (CNS) reactions including confusion and delirium are
associated with the use of intravenous H2 blockers in critically ill postoperative
patients . Patient risk factors for CNS reactions include advanced age, organ
dysfunction, and preexisting cognitive impairment. It is uncertain whether any H2
blocker is less likely to cause CNS effects than others.
• An increased risk of Clostridioides difficile infection has been associated with
proton pump inhibitor use.
Continue/discontinue – Based upon the potential benefits and lack of
contraindications, we recommend that patients who are taking either H2 blockers or
proton pump inhibitors remain on these medications in the perioperative period.
Formulations/alternatives – Patients who are unable to take oral medications for a
prolonged period should be switched to an intravenous form of H2 blocker or proton
pump inhibitor . Intravenous H2 blockers are less costly.

20. PULMONARY AGENTS

21. • Inhaled beta agonists and anticholinergics
Benefit/risk –They have been found to reduce the incidence of postoperative pulmonary
complications in patients with asthma and chronic obstructive pulmonary disease and
should be continued preoperatively.
Continue/discontinue – We recommend continuing beta agonists in the perioperative
period, including the day of surgery.
Formulations/alternatives – Inhaled beta agonists and anticholinergics are normally
administered on the morning of surgery. The drugs can be administered through a nebulizer
or in the circuit of the ventilator when use of metered-dose inhalers is not possible.
Theophylline
●Benefit/risk – There are no data indicating whether continuation of theophylline in the
perioperative period decreases pulmonary complications. Theophylline has the potential to
cause serious arrhythmias and neurotoxicity at a level just beyond the therapeutic range,
and theophylline metabolism is affected by many common perioperative medications.
●Continue/discontinue – We recommend theophylline medications be discontinued the
evening before surgery.
●Formulations/alternatives – Other medications for treatment of obstructive lung disease
can be initiated or adjusted, including inhaled beta agonists, glucocorticoids, and
anticholinergic medications.

22. Glucocorticoids
Benefit/risk – Patients with pulmonary disease who are maintained on glucocorticoids
(corticosteroids) are at risk of adrenal insufficiency if steroids are abruptly withdrawn,
particularly in the face of increased stress related to surgery. Additionally, glucocorticoids in such
patients may be necessary to maintain optimal lung functions. The risk of possible perioperative
complications related to glucocorticoids, including wound infections, is low .
Continue/discontinue – Both inhaled and systemic glucocorticoids should be continued during
the perioperative period.

23. Stress dose:
Nonsuppressed HPA axis — Prednisone doses of less than 5 mg/day given in the morning do not suppress the hypothalamic-pituitary-adrenal
(HPA) axis. The equivalent morning doses of other glucocorticoids (eg, 4 mg/day of methylprednisolone, 0.5 mg/day of dexamethasone, or 20
mg/day of hydrocortisone) will have a similar effect.
– We suggest that the following groups of patients do not need additional perioperative glucocorticoid coverage, because
they are not considered to have suppression of their HPA axis:
– Any patient who has been taking any dose of glucocorticoid for less than three weeks .
– Patients who have received morning doses of less than 5 mg/day of prednisone or its equivalent for any length of time.
– Patients being treated with less than 10 mg of prednisone or its equivalent every other day.

24. Suppressed HPA axis patients:
– Any patient who is currently taking more than 20 mg/day of prednisone or its equivalent (eg, 16 mg/day
of methylprednisolone, 2 mg/day of dexamethasone, or 80 mg/day of hydrocortisone) for more than three
weeks .
– Any patient on glucocorticoids who has clinical Cushing's syndrome

26. ENDOCRINE AGENTS

27. Diabetic medications :
• The goals of perioperative diabetic management include:
– avoidance of hypoglycemia
– prevention of ketoacidosis
– maintenance of fluid and electrolyte balance
– avoidance of marked hyperglycemia.
• During surgical procedures and in the postoperative phase,
we aim to keep the glucose readings between 110 and 180
mg/dL.
• Ideally, all patients with diabetes mellitus should have their
surgery prior to 9 AM to minimize the disruption of their
management routine while being nil per os (NPO).

28. • Sodium-glucose co-transporter 2 (SGLT2)
inhibitors
– Should be stopped three to four days before
surgery .
– These agents increase the risk of urinary tract
infections and hypovolemia. There have also
been reports of acute kidney injury and
euglycemic diabetic ketoacidosis .
– Euglycemic diabetic ketoacidosis may be under-
recognized in the postoperative period, given its
atypical presentation, and closer monitoring of
ketones is required.

29. • Other oral hypoglycemic and/or noninsulin injectable drugs
should be withheld starting on the morning of scheduled
surgery for the reasons stated below:
– Metformin is contraindicated in conditions that increase the risk of
renal hypoperfusion, lactate accumulation, and tissue hypoxia.
– Sulfonylureas and meglitinides can cause hypoglycemia.
– Thiazolidinediones may worsen fluid retention and peripheral edema
and could precipitate congestive heart failure.
– Dipeptidyl peptidase 4 (DPP-4) inhibitors and GLP-1 receptor agonists
could alter gastrointestinal motility . Since DPP-4 inhibitors are
generally considered not to increase the risk of hypoglycemia, some
experts continue DPP-4 inhibitors on the day of surgery

30. – Basal insulin only:
• Patients with type 2 diabetes who take only once-daily basal insulin (eg, NPH,
glargine, detemir, degludec) may continue basal insulin without any change to their
usual regimen, as long as the basal insulin dose has been adjusted appropriately as
an outpatient and results in safe morning glucose levels
• **Patient on Twice-daily dosing basal insulin may also be able to continue their
usual regimen, as long as the basal dose has been correctly calculated.
– Basal and prandial insulin:
• Omit any prandial insulin (regular, lispro, aspart, glulisine) after
fasting begins, typically on the morning of surgery.
• •If basal insulin (eg, NPH, glargine, detemir, degludec) is given
once daily in the morning, advise the patient to give between one-
half to two-thirds of their usual total morning insulin
dose (prandial plus basal insulin) as basal insulin to prevent
ketosis during the procedure.
Pre-mixed insulin –the dose on the evening prior to surgery should
be reduced by approximately 20 percent and the dose on the
morning of surgery by 50 percent . However, if the morning blood
glucose is <120 mg/dL, the morning dose should be held.

31. Drugs used for thyroid disease:
• Continue/discontinue : We recommend perioperative
continuation of therapy for both hyperthyroidism and
hypothyroidism.In the case that a patient cannot take
oral medications for several days, the approach
depends upon the thyroid medication:
– Thyroxine (T4) has a long half-life, and patients on chronic
T4 therapy who are unable to take oral medication for
several days do not need parenteral T4. If oral T4 cannot
be resumed within five to seven days, it should then be
administered parenterally (intravenously or
intramuscularly).
– The antithyroid thionamide medications (methimazole
and propylthiouracil ) have a very short half-life. The
decision on how long to hold antithyroid medications for a
patient who is unable to take oral medications must be
individualized based upon several factors, including the
patient's history of thyroid disease and length of previous
treatment with antithyroid medications.

32. MEDICATIONS AFFECTING HEMOSTASIS

33. Name or class of drug Clinical considerations
Recommended strategy for surgery with
brief NPO state
Recommended strategy
for surgery with
prolonged NPO state
Aspirin
 Continuation may cause
perioperative hemorrhage.
 Discontinuation may increase the
risk of vascular complications.
 Discontinue aspirin ~ 7 days prior to
noncardiovascular surgery.
 Resume with oral intake.
P2Y12 receptor blockers
(clopidogrel, prasugrel,
ticlopidine, ticagrelor)
 When used after cardiac stenting
procedure, if discontinued can
cause cardiac ischemia
perioperatively.
 If continued can result in bleeding
complications.
 Ideally, elective procedures should be
delayed until the mandatory period of
platelet inhibition with these agents is
completed.
 When used for long-term stroke
prophylaxis, should be discontinued 7 to 10
days.
 If discontinuing, stop clopidogrel and
ticagrelor at least 5 days, prasugrel 7 days,
and ticlopidine 10 days before surgery.
 When restarting clopidogrel, consider using
a loading dose.
 Resume with oral intake.
Pentoxifylline
 If being prescribed for alcoholic
hepatitis, consult with prescribing
hepatologist.
 Take last dose the morning of surgery.
However, there is generally no need to
cancel/postpone surgery even if medication
is continued due to low bleeding risk.
 Resume with oral intake.
Perioperative Antiplatelets

34. Perioperative management of patients receiving
anticoagulants

35. Interruption of anticoagulation temporarily increases
thromboembolic risk, and continuing anticoagulation increases the
risk of bleeding associated with invasive procedures; both of these
outcomes can increase mortality rates .
Perioperative management of anticoagulation takes into account
and balances these risks

36. 1. Estimate thromboembolic risk.
2. Estimate bleeding risk.
3. Determine the timing of anticoagulant interruption.
4. Determine whether to use bridging anticoagulation.
5. Example cases.

37. Thromboembolic Risk
Indication for anticoagulant therapy
Mechanical heart valve Atrial fibrillation VTE
High thrombotic risk*
 Any mitral valve prosthesis
 Any caged-ball or tilting disc aortic
valve prosthesis
 Recent (within 6 months) stroke or
transient ischemic attack
 CHADS2 score 5-6
 CHA2DS2-VASc score 7-9
 Recent (within 3 months)
stroke or transient ischemic
attack
 Rheumatic valvular heart
disease
 Recent (within 3 months) VTE
 Severe thrombophilia (eg, deficiency
of protein C, protein S, or
antithrombin; antiphospholipid
antibodies; multiple abnormalities)
Moderate thrombotic
risk
 Bileaflet aortic valve prosthesis
and 1 or more of the of following
risk factors: atrial fibrillation, prior
stroke or transient ischemic attack,
hypertension, diabetes, congestive
heart failure, age >75 years
 CHADS2 score 3-4
 CHA2DS2-VASc score 4-6
 VTE within the past 3 to 12 months
 Nonsevere thrombophilia (eg,
heterozygous factor V Leiden or
prothrombin gene mutation)
 Recurrent VTE
 Active cancer (treated within 6
months or palliative)
Low thrombotic risk
 Bileaflet aortic valve prosthesis
without atrial fibrillation and no
other risk factors for stroke
 CHADS2 score 0-2
 CHA2DS2-VASc score 0-3
(assuming no prior stroke or
transient ischemic attack)
 VTE >12 months previous and no
other risk factors
* Very high-risk patients include those with a prior stroke or TIA occurring >3 months before the planned surgery and a
CHADS2 score <5 or CHA2DS2-VASc score <6 (those with prior thromboembolism during temporary interruption of
anticoagulation, or those undergoing certain types of surgery associated with an increased risk for stroke or other
thromboembolism [eg, cardiac valve replacement, carotid endarterectomy, major vascular surgery]).

38. ESTIMATING PROCEDURAL BLEEDING RISK
• The risk of bleeding is dominated by the type of surgery or procedure.
• Comorbidities (eg, older age, reduced kidney function) and medications that
affect hemostasis.
• Major bleeding is generally defined as bleeding that is fatal, involves a critical
anatomic site (eg, intracranial, pericardial), requires surgery to correct, lowers
the hemoglobin by ≥2 g/dL, or requires transfusion of ≥2 units PRBCs

39. High bleeding risk procedure
(two-day risk of major bleed 2 to 4%)
 Any major operation of duration >45 minutes
 Abdominal aortic aneurysm repair
 Coronary artery bypass
 Endoscopically guided fine-needle aspiration
 Foot/hand/shoulder surgery
 Heart valve replacement
 Hip replacement
 Kidney biopsy
 Knee replacement
 Laminectomy
 Neurosurgical/urologic/head and
neck/abdominal/breast cancer surgery
 Polypectomy, variceal treatment, biliary
sphincterectomy, pneumatic dilatation
 Transurethral prostate resection
 Vascular and general surgery
Low bleeding risk procedure
(two-day risk of major bleed 0 to 2%)
 Abdominal hernia repair
 Abdominal hysterectomy
 Arthroscopic surgery lasting <45 minutes
 Axillary node dissection
 Bronchoscopy with or without biopsy
 Carpal tunnel repair
 Cataract and noncataract eye surgery
 Central venous catheter removal
 Cholecystectomy
 Cutaneous and bladder/prostate/thyroid/breast/lymph node biopsies
 Dilatation and curettage
 Gastrointestinal endoscopy ± biopsy, enteroscopy, biliary/pancreatic stent
without sphincterotomy, endosonography without fine-needle aspiration
 Hemorrhoidal surgery
 Hydrocele repair
 Noncoronary angiography
 Pacemaker and cardiac defibrillator insertion and electrophysiologic
testing
 Thoracentesis
 Tooth extractions
Bleeding Risk

40. DECIDING WHETHER TO INTERRUPT ANTICOAGULATION
• In general, the anticoagulant must be discontinued if the surgical bleeding risk is high.
• Those at very high or high thromboembolic risk should limit the period without
anticoagulation to the shortest possible interval; in some cases, this involves the use of a
bridging agent.

41. Settings requiring anticoagulant interruption
1. If the very high risk of thromboembolism is transient (eg, ischemic stroke within the previous 3
months), attempts should be made to delay elective surgery, if possible, until the
thromboembolic risk has returned to baseline.
2. Individuals with a temporarily very high or high thromboembolic risk in whom surgery cannot be
delayed (eg, potentially curative cancer surgery in a patient who just had an acute VTE) should
limit the interval without an anticoagulant to minimize the risk of VTE recurrence.
3. This generally involves stopping the usual anticoagulant as close to surgery as possible, restarting
it as soon as possible, and, for those on Warfarin, using a bridging agent before and/or after
surgery while the usual anticoagulant is not therapeutic.
4. For individuals with a chronically elevated thromboembolic risk who are receiving warfarin
 Often use bridging anticoagulation to minimize the period when anticoagulation is not
being used.

42. Discontinuation: Typically omit warfarin for 5 days before elective surgery (ie,
the last dose of warfarin is given on day minus 6) and, when possible, check
the PT/INR on the day before surgery.
If the INR is >1.5, Administer a low dose of oral vitamin K (eg, 1 to 2 mg) to
hasten normalization of the PT/INR and recheck the INR the following day.
Proceed with surgery when the INR is ≤1.4.
An INR in the normal range is especially important in patients undergoing surgery
associated with a high bleeding risk (eg, intracranial, spinal, urologic) or if neuraxial
anesthesia is to be used.
Warfarin Interruption.

43. Therapeutic dosing – Therapeutic dosing (also called "full dose") is appropriate for
bridging anticoagulation for individuals with a potential arterial thromboembolic
source (eg, AF, mechanical heart valve) or VTE within the preceding month.
 Typical regimens include Enoxaparin, 1 mg/kg subcutaneously twice daily or Dalteparin, 100 units/kg
subcutaneously twice daily.
Intermediate dosing – Intermediate-dose anticoagulation may be appropriate for
individuals with atrial fibrillation or VTE within the preceding month when bridging
is needed but concerns about bleeding are greater.
 Typical regimens include Enoxaparin, 40 mg twice daily, or Dalteparin, 5000 units subcutaneously twice daily.

44. DOAC Interruptions
 Low/moderate bleed risk – Omit the DOAC one day before and resume one day after the procedure,
provided hemostasis is secure.
 The total duration of interruption is two days.
 High bleed risk – Omit the DOAC two days before and resume two days after the procedure, provided
hemostasis is secure.
 The total duration of interruption is four days.
 Waiting an additional one day before resumption may be appropriate in some cases.
 Impaired kidney function – For individuals with impaired kidney function (CrCl <30 to 50 mL/min) who are
taking dabigatran, there is an additional one day interruption before low/moderate bleeding risk procedures
and an additional two days interruption before high bleeding risk procedures.
 Direct factor Xa inhibitors (Apixaban, Edoxaban, Rivaroxaban) do not require adjustments for kidney function.

45. Temporary IVC filters
• Indicated in patients with a very recent (within the prior three to
four weeks) acute VTE who require interruption of anticoagulation
for a surgery or major procedure in which it is anticipated that
therapeutic-dose anticoagulation will need to be delayed for more
than 12 hours postoperatively

46. Settings in which continuing the anticoagulant may
be preferable

47. Timing for interruption of a DOAC before and after elective surgery
 This strategy applies to all DOACs in individuals with normal kidney function (eg, CrCl >50 mL/min) and
individuals taking Apixaban, Edoxaban, or Rivaroxaban with CrCl 30 to 50 mL/min.
 For individuals taking Dabigatran who have CrCl of 30 to 50 mL/min, omit an additional dose before the
procedure.
 For any DOAC and a high bleeding risk procedure, it may be reasonable to omit the DOAC for an additional
postoperative day (5 days total interruption).

48. Anticoagulant Renal function and dose
Interval between last dose and procedure
NOTE: No anticoagulant is administered the day of the
procedure
Resumption after procedure
High bleeding risk Low bleeding risk High bleeding risk Low bleeding risk
Dabigatran
CrCl >50 mL/minute
Dose 150 mg twice daily
Give last dose three days
before procedure (ie, skip four
doses on the two days before
the procedure)
Give last dose two days
before procedure (ie, skip
two doses on the day before
the procedure)
Resume
48
to
72
hours
after
surgery
(ie,
postoperative
day
2
to
3)
Resume
24
hours
after
surgery
(ie,
postoperative
day
1)
CrCl 30 to 50 mL/minute
Dose 150 mg twice daily
Give last dose five days before
procedure (ie, skip eight doses
on the four days before the
procedure)
Give last dose three days
before procedure (ie, skip
four doses on the two days
before the procedure)
Rivaroxaban
CrCl >50 mL/minute
Dose 20 mg once daily
Give last dose three days
before procedure (ie, skip two
doses on the two days before
the procedure)
Give last dose two days
before procedure (ie, skip
one dose on the day before
the procedure)
CrCl 30 to 50 mL/minute
Dose 15 mg once daily
Apixaban
CrCl >50 mL/minute
Dose 5 mg twice daily
Give last dose three days
before procedure (ie, skip four
doses on the two days before
the procedure)
Give last dose two days
before procedure (ie, skip
two doses on the day before
the procedure)
CrCl ≤50 mL/minute
Dose 2.5 mg twice daily
Edoxaban
CrCl 51 to 95 mL/minute
Dose 60 mg once daily
Give the last dose three days
before the procedure (ie, skip
two doses on the two days
before the procedure)
Give the last dose two days
before the procedure (ie,
skip one dose on the day
before the procedure)
CrCl ≤50 mL/minute*
Dose 30 mg once daily
Perioperative management of oral direct thrombin inhibitors and factor Xa inhibitors

49. BRIDGING ANTICOAGULATION
• Bridging may be appropriate during Warfarin discontinuation in the following individuals:
1. Mechanical mitral valve; mechanical aortic valve with additional stroke risk
factors.
2. Embolic stroke within the previous three months or very high stroke risk (eg,
CHADS2 score of 5 or 6).
3. VTE within the previous 3 months.
4. Possibly in selected individuals with recent coronary stenting.
5. Previous thromboembolism during interruption of chronic anticoagulation.

50. A 76-year-old female with nonvalvular AF , HTN, and prior stroke three months
ago, receiving warfarin, requires elective hip replacement with neuraxial
anesthesia; kidney function is normal, .and weight is 75 kg
This patient has a very high thromboembolic risk , and a high bleeding risk .
1. Omit warfarin for five days before the procedure (last dose on preoperative day minus 6).
2. Preoperative bridging with therapeutic-dose low molecular weight (LMW) heparin
(eg, dalteparin, 100 units/kg [7500 units] subcutaneously twice daily) starting on
preoperative day minus 3, with last dose on the morning of day minus 1.
3. Resume warfarin within 24 hours after surgery (usual dose).
4. Postoperative low-dose LMW heparin for venous thromboembolism (VTE) prevention
(eg, dalteparin, 5000 units subcutaneously once daily) within 24 hours after surgery until
postoperative bridging is started.
5. Postoperative bridging on postoperative day 2 or 3, when hemostasis is secured
(eg, dalteparin, 100 units/kg [7500 units] subcutaneously twice daily); continue for at
least four to five days, until the international normalized ratio (INR) is therapeutic.

51. A 70-year-old male with nonvalvular atrial fibrillation, diabetes, and hypertension (CHA2DS2-
VASc score = 3) receiving dabigatran who requires a colon resection for cancer; kidney
function is normal.
This patient has a moderate thrombotic risk and a high bleeding risk .
1. Omit dabigatran for two days before the procedure (last dose of dabigatran on day minus 3).
2. No bridging.
3. Resume dabigatran on postoperative day 2 or 3, when patient is able to take medication by mouth.
4. Use prophylactic-dose LMW heparin for VTE prophylaxis for the first two to three postoperative days.

52. A 55-year-old male with an unprovoked DVT four months ago, receiving apixaban 5 mg twice
daily, who requires a colonoscopy because of a personal history of premalignant colorectal
polyps; kidney function is normal.
This patient has a high thrombotic risk and a low bleeding risk .
1. Omit apixaban for one day before the procedure (last dose of apixaban on day minus 2).
2. No bridging.
3. Resume apixaban the day after the procedure, after at least 24 hours have elapsed and when
hemostasis is secured.
4. If the patient requires polyp removal, delay resumption of apixaban for one to two more days.

53. A 68-year-old female with nonvalvular atrial fibrillation, hypertension, and congestive heart failure (CHA2DS2-
VASc score = 4), receiving rivaroxaban 15 mg daily in the morning, requires a dental cleaning and two dental
extractions; creatinine clearance (CrCl) is 35 mL/min.
This patient has a high thrombotic risk and a low bleeding risk .
1. Omit rivaroxaban on the day of the procedure.
2. Use oral tranexamic acid mouthwash just before the procedure and two to three times that day
after the procedure.
3. Resume rivaroxaban the day after the procedure, after at least 24 hours have elapsed (assuming the
dental extractions were uneventful).

54. THANK YOU