Appendix 3: Bridging of patients on direct oral anticoagulants (DOACs) before surgery or invasive procedures

Acute Oncology Guidelines
NHS Lothian

Per-operatively

Surgical interventions or invasive procedures that carry a minor or major bleeding risk require temporary discontinuation of the DOAC (see below). For each patient, individual factors relating to bleeding and thrombo-embolic risk need to be considered and should be discussed with the treating physician.  These factors include:  

  • renal function 
  • patient age 
  • history of bleeding complications 
  • concomitant medication 
  • operative bleeding risk .

Because of the predictable properties of DOACs there is no need for pre-operative low molecular weight heparin (LMWH) bridging. It is not recommended that IV heparin is used routinely as a bridge before procedures. 

Post-operatively

Initially use LMWH at prophylactic doses (starting at the later of 4 hours post-op or at 1800 on the day of the surgery) and increase towards therapeutic doses on day 2-3 post-op. Once post-op haemostasis is safely secured and bleeding risk has subsided, therapeutic doses of DOAC can be restarted 24 hours after the last dose of LMWH.  

Classification of elective surgical interventions according to bleeding risk

Discontinuation not required Minor bleeding risk

 Major bleeding risk
  • Dental interventions: extraction of 1 to 3 teeth, paradontal surgery, incision of abscess, implant positioning 
  • Ophthalmology: cataract / glaucoma interventions  
  • Endoscopy without biopsy  
  • Superficial surgery (e.g. abscess incision, dermatology)  
  • Endoscopy with biopsy 
  • Hickman line insertion 
  • Prostate / bladder biopsy 
  • Electrophysiological study or catheter ablation of simple right sided SVT  
  • Non coronary angiography  
  • Routine pacemaker / ICD implantation
  • Liver or kidney biopsy 
  • Transurethral prostate resection  
  • Spinal or epidural anaesthesia or diagnostic lumbar puncture  
  • Thoracic, abdominal or major orthopaedic surgery  
  • Extracorporeal shockwave lithotripsy  
  • Catheter ablation of simple left-sided SVT  
Time after last dose of DOAC to surgical intervention or invasive procedure 
Discontinuation not required Minor bleeding risk

 Major bleeding risk
No important bleeding risk and/or adequate local haemostasis possible: perform procedure at trough level (i.e. ≥12 or 24h after last DOAC dose) 


 CrCl ≥30mL/min ≥24h from last DOAC dose  ≥48h from last DOAC dose 
CrCl 15-29 mL/min ≥36h from last DOAC dose, consider checking anti-Xa pre-op   ≥48h from last DOAC dose, consider checking anti-Xa pre-op
CrCl <15 mL/min Contraindicated

Editorial Information

Last reviewed: 01/12/2021

Next review date: 01/12/2024

Author(s): Dalrymple H.

Version: 2.1

Approved By: CTAC Chair

Reviewer name(s): Stewart J.