Perioperative management of oral direct thrombin inhibitors and factor Xa inhibitors

Anticoagulant	Kidney 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 3 days before procedure (ie, skip 4 doses on the 2 days before the procedure)	Give last dose 2 days before procedure (ie, skip 2 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 5 days before procedure (ie, skip 8 doses on the 4 days before the procedure)	Give last dose 3 days before procedure (ie, skip 4 doses on the 2 days before the procedure)
Rivaroxaban	CrCl >50 mL/minute Dose 20 mg once daily	Give last dose 3 days before procedure (ie, skip 2 doses on the 2 days before the procedure)	Give last dose 2 days before procedure (ie, skip 1 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 3 days before procedure (ie, skip 4 doses on the 2 days before the procedure)	Give last dose 2 days before procedure (ie, skip 2 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 3 days before the procedure (ie, skip 2 doses on the 2 days before the procedure)	Give the last dose 2 days before the procedure (ie, skip 2 dose on the day before the procedure)
	CrCl ≤50 mL/minute* Dose 30 mg once daily

Bleeding risk is determined primarily by the type of surgery; patient comorbidities may also play a role. In patients undergoing neuraxial anesthesia or a very high bleeding risk procedure, a longer period of interruption may be warranted. In many low bleeding risk procedures, the anticoagulant does not need to be interrupted. Bridging anticoagulation may be appropriate preoperatively in patients with a very high thromboembolic risk who require more prolonged interruption of the anticoagulant (eg, for renal insufficiency) and/or postoperatively in patients who are unable to resume the anticoagulant (eg, unable to take oral medication due to intestinal ileus). Refer to the UpToDate topics on perioperative management of patients receiving anticoagulants for further details.

CrCl: creatinine clearance.

* Product information varies in different countries regarding a lower limit of CrCl below which the drug should not be used. As an example, product information in the United States specifies avoiding use with CrCl <15 mL/minute.

Graphic 93260 Version 12.0

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Perioperative management of oral direct thrombin inhibitors and factor Xa inhibitors