Only publications in English were considered.ĭabigatran (a direct anti-IIa inhibitor), rivaroxaban and apixaban (two direct anti-Xa inhibitors) are licensed in the European Union for the prevention of venous thromboembolism (VTE) after orthopedic surgery (hip and knee arthroplasties), for the prevention of thromboembolic events due to non-valvular atrial fibrillation (NVAF), and in the treatment or secondary prophylaxis of VTE. The literature search was performed in PubMed using the following keywords: perioperative, anticoagulant, dabigatran, rivaroxaban, edoxaban and apixaban. This review aims to summarize current guidance on the perioperative management of DOACs to reflect published research. Furthermore, antidotes are gradually being licensed. Nowadays, around 10–15% of patients on DOACs will have to interrupt their anticoagulant before an invasive procedure every year. More recently, sub-group analyses of the phase III trials as well as results of recent clinical studies have influenced further guidelines. Several expert guidelines were developed as soon as DOACs became available to help physicians manage these drugs. However, the perioperative management and monitoring of DOACs has proved to be challenging, especially as antidotes were not available immediately following their introduction. Rapid onset and offset of action, short half-life and predictable anticoagulant effects without the need for routine monitoring were the key strengths on which these anticoagulants have been marketed. The number of patients receiving treatment with direct oral anticoagulants (DOACs) is increasing, as clinical trials have demonstrated non-inferiority or superiority in terms of prevention and treatment of thrombo-embolic events compared with vitamin K antagonists (VKAs). This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure.Īs antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. Each year, 10–15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications.
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