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

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. 

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.