A 78 yo lady is on rivaroxaban 15mg po daily for atrial fibrillation. She had a scheduled elective procedure on Friday for which the surgeon has requested the rivaroxaban be held for the previous 2 days before the procedure. The order was transcribed as “Hold Rivaroxaban for 2 days, restart on Friday”. The intent of the order was to restart rivaroxaban after the procedure. No one made the connection that the rivaroxaban was scheduled at 0800 in the morning. So on Friday the morning of the procedure, the patient was given a dose of rivaroxaban. Unfortunately, the procedure had to be cancelled due to the administration of rivaroxaban.
A patient may be asked to hold his or her anticoagulant when undergoing a procedure. Unlike warfarin where the INR can confirm the level of anticoagulation, there is no universal laboratory test available for DOACs. The management strategy is guided by the following:
- The half life of the medication:
- In general, the longer the half life of the medication, the longer it will take to reverse the anticoagulation effect of the medication.
- The relationship between renal function and drug elimination:
- All DOACs are renally eliminated. Therefore it becomes much more difficult to reverse the anticoagulation effect in someone who has severe renal impairment.
- The bleeding risks of the procedure:
- If the procedure is associated with high bleeding risk, it may influence the decision as to how long to hold the DOAC to ensure adequate reversal of anticoagulation.
Thrombosis Canada has developed a comprehensive document around the perioperative management with DOAC, along with an online tool which can come in handy for the day-to-day guidance and support. I encourage you to check out their resources and tools.
As in the case of rivaroxaban, below are the suggested guidelines as per Thrombosis Canada:
- For individuals with normal renal function, mild or moderate impairment (CrCL ≥ 30mL/min):
- Minor surgery / procedure with low bleeding risk: Give last dose 2 days before surgery / procedure (e.g. skip 1 dose)
- Major surgery / procedure including neuraxial procedures with high bleeding risk): Give last dose 3 days before surgery / procedure (e.g. skip 2 doses)
How do you ensure these instructions are clearly and accurately executed for the patient?
To minimize misunderstanding or similar incidents from occurring, here are some considerations around writing orders to hold DOAC for pre-operative management:
- Suggest to specify the reason for holding the medication (e.g. Going for Hernia repair)
- Indicate the date (and time if known) of the procedure (e.g. scheduled procedure on April 14, 2017)
- Specify both the last dose to take before the procedure as well as the doses to skip (e.g. Give / take rivaroxaban on April 12, skip rivaroxaban on April 13 and 14th)
- If the DOAC involves BID dosing, suggest to specify instructions for both morning and evening doses (instead of number of days).
- It may be helpful to include a table as follow:
What about post-operative management?
- It would be preferred to also specify when the DOAC can be restarted, relative to the time and date of the surgery / procedure (e.g. restart rivaroxaban 24 hours after the hernia repair on April 15).
- If the date and time to restart a DOAC may not be known before the surgery or procedure, then the clinician must be diligent to follow up to ensure the DOAC is restarted as appropriate. I have seen many instances where the DOAC or warfarin has not been resumed, exposing the patient to unnecessary stroke or thrombolic risk in the interim.
I hope this post provides some guidance for clinicians when writing orders for perioperative management of DOACs. Many resources go into scheduling and planning for any surgery or procedure. It would be very unfortunate to see these resources go to waste because the perioperative instructions of DOAC are not clear or misinterpreted. In addition, delaying the surgery / procedure will lead to disappointment, inconvenience and potentially other forms of harm or prolonged risk for the patient.
Let’s be wise and pay more attention when writing perioperative orders for DOACs. And this applies to other anticoagulants and antiplatelets as well!
Thank you for reading my post!