Anticoagulants

• Xarelto (rivaroxaban)
  • factor Xa inhibitor
  • measure small elevation in INR/PTT; anti-factor Xa level
  • stop 24hrs prior to surgery
  • possible partial reversal with aPCC, may need 12hr re-dosing.
• Eliquis (apixaban)
  • factor Xa inhibitor
  • measure small elevation in INR/PTT; anti-factor Xa level
  • stop 48hrs prior to surgery
  • possible partial reversal with aPCC, may need 12hr re-dosing.
• Savaysa (edoxaban)
  • factor Xa inhibitor
  • measure small elevation in INR/PTT
  • stop 24hrs prior to surgery
  • possible partial reversal with aPCC, may need 12hr re-dosing.
• Pradaxa (dabigatran)
  • direct thrombin inhibitor
  • measure elevated INR/PTT
  • stop 1-2d prior to surgery if CrCl>50ml/min or stop 3-5d prior to surgery if CrCl<50ml/min; may need longer times for major surgery
  • partial reversal with PCC and dialysis
  • full reversal with idarucizumab 2.5g x2 15min apart; immediate onset; lasts 24hrs.
• Argatroban
  • direct thrombin inhibitor
  • measure elevated INR/PTT
  • stop 4hrs before surgery
  • no reversal
• bivalirudin
  • direct thrombin inhibitor
  • elevated PTT
  • stop 2hrs before surgery
  • reverse partially with dialysis and rFVIIa
• fondiaparinux
  • factor Xa inhibitor
  • measure possibly elevated anti-factor Xa level
  • stop 4d before surgery
  • possible partial reversal with aPCC, may need 12hr re-dosing; rFVIIa
• Deltaparin / Lovenox LMWH
  • indirect thrombin inhibitor
  • measure anti-factor Xa level
  • stop 1d prior to surgery
  • partial reversal with protamine
• Plavix (clopidogrel)
  • blocks ADP receptor on platelets
  • measure platelet function assay, ROTEM, TEG with platelet mapping
  • stop 7d before surgery
  • partial reversal options include: 10U platelets, DDAVP ug/kg IV re-dosed PRN 8-12hrs, possibly TXA
• Pletal (cilostazol)
  • phosphodiesterase inhibitor (increases cAMP), reversible platelet aggregation inhibitor
  • no measure
  • unsure, may stop 7d before surgery
  • no reversal
• Effient (prasugel)
  • blocks ADP receptor on platelets
  • stop 7d before surgery
  • partial reversal options include: 10U platelets, DDAVP ug/kg IV re-dosed PRN 8-12hrs, possibly TXA
• Brillanta (ticagrelor)
  • reversibly blocks ADP receptor
  • stop 5d before surgery
  • partial reversal options include: 10U platelets, DDAVP ug/kg IV re-dosed PRN 8-12hrs, possibly TXA
• Ticlid (ticlopidine)
  • blocks ADP receptor on platelets
  • stop 10-14d before surgery
  • partial reversal options include: 10U platelets, DDAVP ug/kg IV re-dosed PRN 8-12hrs, possibly TXA
• Persantine (dipyridamole)
  • increases cAMP
  • stop 48hrs before surgery
• Aggrenox (asa/dipyridamole)
  • antiplatelet COX inhibitor and increases cAMP
  • stop 7d before surgery
  • partial reversal options: platelets
• ReoPro (abciximab)
  • inhibits GP IIb/IIIa
  • stop 36-48hrs before surgery
  • partial reversal options include: 10U platelets, DDAVP ug/kg IV re-dosed PRN 8-12hrs, TXA
• Integrilin (eptifibatide)
  • inhibits GP IIb/IIIa
  • stop 4-6hrs before surgery
  • partial reversal with DDAVP; wait to give platelets until medication is cleared

References:

https://www.ucdmc.ucdavis.edu/anticoag/pdf/AnticoagReversal.pdf - reversal

http://www.unmc.edu/anesthesia/education/preoperative-medication-management-13.pdf - when to hold before surgery

http://www.practical-haemostasis.com/Platelets/platelet_function_testing_pfa100.html - platelet function assay results

individual drug web sites

Summary of Guidelines for the Perioperative Management of Antithrombotic Medications

DOAC, direct oral anticoagulant; LMWH, low-molecular-weight-heparin; PCC, prothrombin complex concentrate; PCI, percutaneous coronary intervention; VTE, venous thromboembolism.

Reference: https://www.journalacs.org/article/S1072-7515(18)31331-0/fulltext