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