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Issues for surgery

For prevention or treatment of venous thromboembolism (VTE) - risk of VTE if omitted.

For prevention of stroke - risk of arterial embolism (e.g. cerebrovascular event, CVA) if omitted.

Risk of bleeding and / or complications of bleeding if continued.

Risk of epidural or spinal haematoma if continued prior to neuraxial anaesthesia.

Advice in the perioperative period

Elective surgery 

Step 1 – determine indication

For deep vein thrombosis (DVT) or pulmonary embolism (PE) within last 3 months – refer to Haematologist to determine appropriate course of action.

Step 2 – determine if dose appropriate for patient

The guidance below assumes that the patient is on an appropriate dose of dabigatran in relation to the indication, their renal function, age, weight, and concomitant interacting medication – see current product literature to establish that the patient is on the appropriate dose.

When estimating renal function use Cockcroft-Gault (C&G) creatinine clearance (CrCl) rather than estimated glomerular filtration rate (GFR), to avoid overestimating renal function, particularly in the elderly or at extremes of body weight. It is recommended to use actual weight rather than ideal body weight.

Dabigatran is contraindicated if CrCl less than 30ml/min – such patients should be immediately referred to a Haematologist.

Step 3 – determine bleeding risk for surgery / procedure

For examples of minor, low / moderate and high bleeding risk surgical procedures and low and high-risk endoscopic procedures see Anticoagulants - Overview.

Step 4 – decision on pre-operative cessation

Minor bleeding risk surgery / procedure (not endoscopic)

Most minor bleeding risk procedures and those procedures where any bleeding is easily controllable, can be undertaken safely without dabigatran interruption (where possible time the procedure for 12 hours after the last dose).

Low bleeding risk endoscopic procedure / low or moderate bleeding risk surgery / procedure (not endoscopic) / high bleeding risk surgery or procedure / cardiac surgery / neuraxial anaesthesia

Bleeding risk of surgery / procedure	Creatinine Clearance (CrCl)	Day -4	Day -3	Day -2	Day -1	Day of surgery / procedure	Total number of doses omitted
Low risk endoscopic procedure	N/A	Continue	Continue	Continue	Continue	Omit morning dose	ONE dose
Low / moderate risk (not endoscopic)	CrCl equal to or greater than 50 ml/min	Continue	Continue	Continue	Omit doses	Omit morning dose	THREE doses
Low / moderate risk (not endoscopic)	CrCl between 30 and 49 ml/min	Continue	Continue	Omit doses	Omit doses	Omit morning dose	FIVE doses
High risk (including endoscopic and cardiac) / neuraxial anaesthesia	CrCl equal to or greater than 50 ml/min	Continue	Continue	Omit doses	Omit doses	Omit morning dose	FIVE doses
High risk (including endoscopic and cardiac) / neuraxial anaesthesia	CrCl between 30 and 49 ml/min	Omit doses	Omit doses	Omit doses	Omit doses	Omit morning dose	NINE doses

Bridging therapy

Bridging with therapeutic dose low molecular weight heparin (LMWH) pre-procedure is not required for patients on dabigatran; see Anticoagulants – Overview.

Emergency surgery / procedure

Determine urgency of surgery / procedure.

For acute emergency procedures (which need to occur immediately)

Discontinue dabigatran.

Contact Haematologist to discuss:

• use of prohaemostatic agents (see below)
• appropriateness of coagulation studies and, where available, dabigatran levels - note a normal PT or aPTT does not exclude an anticoagulant effect

For urgent procedures (which need to occur within hours)

Discontinue dabigatran.

Delay procedure, if possible, for 24 hours (and at least 12 hours) after last dose of dabigatran to allow plasma levels to fall.

If the procedure cannot be delayed the risk of bleeding should be weighed against the urgency of the intervention.

If an anticoagulant effect cannot be excluded neuraxial interventions should be avoided.

Expedited procedures (which need to occur within a few days)

Discontinue dabigatran.

Follow advice under Elective surgery.

Prohaemostatic agents

The use of prohaemostatic agents might reduce the risk of peri-surgical bleeding in patients on dabigatran who require emergency surgery. Discussion with a Haematologist should take place to review the measures that can be taken to control bleeding prior to and during urgent surgery.

The following agents may be considered: -

• Tranexamic acid is likely to reduce bleeding and should be considered for all patients on a DOAC prior to emergency surgery. It can be administered intravenously (IV) or orally (PO) (usual dose 1g three times a day)
• Prothrombin Complex Concentrate (PCC) can be considered, despite the lack of evidence for efficacy and safety, although routine use is not recommended. The usual view of clinicians is that PCC might improve outcomes, but this does not take into consideration the potential for adverse thrombotic events. A pragmatic approach might be to proceed with surgery, considering PCC in the event of diffuse coagulopathic bleeding. Consultant Haematologist advice must be sought before use of PCC.
• Idarucizumab (Praxbind^®) is licensed for rapid reversal of dabigatran in emergency surgery, urgent procedures, and life threatening / uncontrolled bleeding. A second dose may be required at 24 hours after the initial dose, particularly in patients with CrCl less than 50ml/min (see current product literature). A Haematologist should be contacted to discuss patients who have a prolonged thrombin time and / or abnormal post-operative bleeding at 24 hours following the initial dose.

Perioperative considerations

Neuraxial (spinal / epidural) interventions or lumbar punctures

Experience is limited with the use of dabigatran around neuraxial interventions and an acceptable level of residual dabigatran activity to proceed with neuraxial anaesthesia is undetermined; hence, there is a risk of developing an epidural or spinal haematoma that can result in long-term paralysis.

Risk factors include use of post-operative indwelling epidural catheters (vs ‘single-shot’ techniques), concomitant use of medications affecting haemostasis and traumatic or repeated epidural / spinal puncture. Before performing neuraxial intervention see Further information below.

Indwelling catheter removal advice

Continuation of dabigatran should be avoided in patients requiring neuraxial interventions. Dabigatran should not be administered with an indwelling catheter in situ. If anticoagulation is required, prophylactic LMWH can be considered whilst a post-operative catheter is in situ.

The next dose of dabigatran should be administered at least 2 hours after neuraxial puncture or withdrawal of neuraxial catheter. However, it may be prudent to delay administration by up to 24 hours where the bleeding risk is deemed to be particularly high, for example, in the event of traumatic puncture or poor renal function / advanced age.

Post-operative advice

Attention to post-operative haemostasis is clinically important since too early resumption of dabigatran, especially within 24 hours of surgery, may be associated with increased risk of major bleeding. Dabigatran is rapidly absorbed and has a fast onset of action with peak anticoagulant activity at approximately 3 hours after the first dose.

For patients who have an indwelling catheter – see Indwelling catheter removal advice above.

Bleeding risk of procedure / surgery	Time to restart post procedure / surgery	Comments
Minor risk	6 - 12 hours	With immediate and complete haemostasis
Low risk endoscopic	6 - 12 hours	With immediate and complete haemostasis
Low / moderate risk (not endoscopic)	24 hours	-
High risk (including endoscopic)	48 - 72 hours	Consider prophylactic LMWH starting 6 - 12 hours post-operatively until dabigatran can be safely restarted Treatment doses may be considered necessary depending on patient's thromboembolic risk. LMWH should be discontinued as soon as dabigatran can be restarted

Patients undergoing cardiac surgery

Some cardiac surgery may warrant the use of post-operative unfractionated heparin (UFH). The UFH should be discontinued as soon as rivaroxaban can be restarted. However, reinitiation of dabigatran may not be appropriate following certain cardiac surgical procedures and advice should be sought from a Cardiologist / Haematologist as necessary.

Patients with reduced oral absorption post-operatively

For patients with a reduction in oral absorption post-operatively e.g. post-operative ileus, gastrointestinal (GI) surgery, nausea and vomiting; consider use of prophylactic LMWH starting 6 – 12 hours post-operatively until oral treatment can be safely resumed. Treatment doses may be necessary depending on the patient’s thromboembolic risk. The LMWH should be discontinued as soon as the dabigatran is restarted.

Patients undergoing bariatric surgery

Dabigatran is not recommended in the immediate post-operative period following bariatric surgery and patients should be commenced on low molecular weight heparin (as per local guidelines) for a period of at least 4 weeks. Absorption of dabigatran may be reduced following bariatric surgery due to higher pH and use of antacids; hence, it may not be the preferred anticoagulant of choice. Advice should be sought from a Haematologist. 

Initiation for VTE prophylaxis following arthroplasty

Dabigatran for the prevention of VTE following hip or knee arthroplasty should commence 1 – 4 hours following surgery if haemostasis is secured. See current product literature for dosing advice.

Interactions with common anaesthetic agents

None.

Interactions with other common medicines used in the perioperative period

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are predicted to increase the risk of bleeding when given with dabigatran and are ideally avoided. If there is no suitable analgesic alternative and benefit outweighs risk, cautious use may be considered for the shortest time possible; consider use of a gastroprotective agent (e.g. proton pump inhibitor).

Low molecular weight heparin (LWMH) / unfractionated heparin (UFH)

The concurrent use of dabigatran with LMWH / UFH, increases the risk of bleeding and is contraindicated (unless under specific circumstances and as advised by a specialist). LMWH must be discontinued immediately upon recommencing dabigatran.

Antimicrobials

Clarithromycin and possibly erythromycin, increases the exposure to dabigatran, especially with concurrent renal impairment. 

Whilst single surgical prophylactic doses should not pose a problem, continued post-operative treatment may require close monitoring for excessive bleeding - consult current product literature.

Further information

Rationale for perioperative advice

The British Society for Haematology (BSH), the European Society of Cardiology (ESC) and the American College of Chest Physicians (ACCP) all support the standardised management of treatment dose DOAC in the majority of patients undergoing elective low or high bleeding risk procedures. This is based on the PAUSE study that utilised a standardised perioperative DOAC management protocol, without routine pre-operative LWMH bridging. The authors concluded that this approach was associated with low rates of major bleeding and arterial thromboembolism. Note that only patients being treated for atrial fibrillation, on doses of 110mg or 150mg twice daily, with CrCl equal to or greater than 30ml/min were included in the study.

Individualisation of dabigatran cessation pre-operatively may still be required, however, based on individual patient characteristics. If there is any doubt as to the pre-operative cessation of DOAC therapy in a patient, due to specific patient characteristics i.e. weight less than 50Kg, advanced age, concomitant interacting medication; it may be prudent to discuss with a Haematologist.

Neuraxial (spinal / epidural) anaesthesia or lumbar punctures

An acceptable level of residual dabigatran activity to proceed with neuraxial intervention remains undetermined. Suggested time intervals for neuraxial intervention after the last dabigatran administration depends on the dose (prophylactic or treatment), half-life and patient’s renal function. There should be consideration of concomitant medicines that might increase plasma dabigatran levels, especially in the elderly or patients with concurrent renal impairment.

Whereas the AAGBI guidelines recommend a shorter stopping time, these guidelines are currently under review, and a broad consensus in the more recently published guidelines is that the time interval between last dabigatran dose and neuraxial anaesthesia should be five half-lives for treatment doses and two half-lives for prophylactic doses. In practice, this aligns with the recommendations above for ‘high bleeding risk surgery’ which are based on the PAUSE trial where 8.5% of the dabigatran cohort had neuraxial anaesthesia. However, if there is any doubt to the safety of performing neuraxial anaesthesia the decision to proceed should involve a discussion between the anaesthetist and the patient, via a shared decision-making process, on the day of surgery.

Information for patients / carers

All patients (or carers if applicable) should receive written information in relation to the anticipated date of their procedure, including the date and time of their last dose of dabigatran. The NUMBER of doses to omit pre-operatively should be communicated, not the number of days / hours, as this may lead to confusion about the appropriate time to stop.

References

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