The New Oral Anticoagulants and Anesthesia

  • Davide Chiumello
  • Paolo Spanu


The oral anticoagulant therapy (OAT), used for prevention and treatment of thromboembolic disease, has been performed in clinical practice, before 2011, using dicumarolic drugs only.

The INR control into the therapeutic range with warfarin is difficult to achieve and to maintain because of the pharmacodynamic and pharmacokinetic property. The patients need frequent INR tests and change of weekly dosage. The slow onset (3–6 days to reach the therapeutic range) and long half-life promoted research for development of new agents.

The new oral anticoagulants (NOACs) came into this context with the advantages to be oral drugs and having the advantages of low-molecular-weight heparin (LMWH) which do not require routine monitoring and dose adjustment as required with warfarin or heparin.

The NOACs show a high therapeutic index, rapid onset of anticoagulant effect, low half-life, low interaction with drug or food, and fixed daily dosage.

The management of patient in NOAC therapy for surgery or anaesthesiology treatments is increasing now. Very important is the knowledge about the new oral anticoagulants for the right management of the risk of bleeding or thrombosis complications during the periods of pre-intra-post scheduled or unscheduled surgery.

The new oral anticoagulants have great advantages in spite of the effects of the sanitary costs compared to previous and conventional anticoagulant therapy.

The therapeutic indications based on randomised clinical trials were approved by the European Medicines Agency (EMA) and in Italy by the Agenzia Italiana del Farmaco (AIFA) introducing the NOA into European and Italian clinical protocols.

The NOACs compared with vitamin K antagonist (VKA) such as warfarin, acenocumarol, and heparin (LMWH and unfractionated UFH) have the same efficiency and safety for thromboprophylaxis after major orthopaedic surgery and treatment of venous thromboembolism, pulmonary embolism, and thromboembolic events in non-valvular atrial fibrillation.

The results coming from trials from 2011 to 2013, contribute to introduce the NOACs in anticoagulant therapy in Italy and Europe with EMA and AIFA approbation.

An important help to clinicians came from the guidelines giving valuation of bleeding or thrombosis risk through the scores. The surgery interventions and regional anaesthesia have the same impact on risk: the anaesthesia neuraxial invasive procedure presents bleeding risk equal to major surgery.

Another concept focused is about the peridural haematoma which presents the same risk during the procedure of positioning and during catheter removing.

With regard to anaesthesiology and surgery procedures, the problem is discontinuation of NOAC therapy: the interval safety between stop and restarting and indication for bridge therapy, but there are not absolute indications to guarantee no risk of bleeding or thrombotic complications. So every patient with low or high risk of bleeding/thrombosis must be carefully monitored in their clinical condition during pre - and post-surgery and anaesthesia periods.


Anticoagulants New oral anticoagulants (NOACs) Regional anaesthesia Bleeding risk Thrombosis risk 


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Davide Chiumello
    • 1
  • Paolo Spanu
    • 2
  1. 1.SC Anestesia e RianimazioneASST Santi Paolo e CarloMilanItaly
  2. 2.Dipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanItaly

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