Management of Elective Surgery and Emergent Bleeding with Direct Oral Anticoagulants
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Purpose of Review
The purpose of this review was to offer practical management strategies for when patients receiving direct oral anticoagulants require elective surgery or present with bleeding complications.
Clinical practice guidelines are now available on the timing of periprocedural interruption of treatment with the newer direct oral anticoagulants based on their pharmacodynamics and pharmacokinetics and based on findings from cohort studies and clinical trials. An antibody that reverses the effects of dabigatran is now available, and a factor Xa decoy is being developed as an antidote to apixaban, betrixaban, edoxaban, and rivaroxaban.
The timing of interruption of direct oral anticoagulants for elective surgery is based on multiple factors, including pharmacologic properties and interactions, the patient’s renal function, and the type of planned surgery. There is little role for low-molecular-weight heparin bridging. Idarucizumab is the treatment of choice for dabigatran-related life-threatening bleeding, while andexanet alfa is being developed to reverse factor Xa inhibitors.
KeywordsDirect oral anticoagulants (DOAC) Reversal Bleeding Surgery Idarucizumab Andexanet alfa
Compliance with Ethical Standards
Conflict of Interest
Dr. Scott Kaatz has received research funding from Janssen; Speaker honorarium from Janssen, Boehringer-Ingelheim, Bristol Myer Squibb, Pfizer, CSL Behring, and Daiichi Sankyo; and consultant fees from Boehringer Ingelheim, Bristol Myer Squibb, Pfizer, Janssen, Daiichi Sankyo, Portola and Roche.
Dr. Charles E. Mahan has received speaker honoraria from Janssen, Bristol Myer Squibb, Pfizer, Portola, and Boehringer Ingelheim; and consultant fees from Janssen, Pfizer, Portola, and Daiichi Sankyo.
Drs Asaad Nakhle, Kulothungan Gunasekaran, Mahmoud Ali, Robert Lavender, and David G. Paje have nothing to disclose.
Human and Animal Rights and Informed Consent
This review article did not involve human or animal experimentation.
Papers of particular interest, published recently, have been highlighted as: • Of importance
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