Table 4

Preoperative interruption of new oral anticoagulants: a suggested management approach

Drug (dose)*Patient renal functionLow bleeding risk surgery† (2 or 3 drug half-lives between last dose and surgery)High bleeding risk surgery‡ (4 or 5 drug half-lives between last dose and surgery)
Dabigatran (150 mg twice daily)    
    t1/2 = 14-17 h Normal or mild impairment (CrCl > 50 mL/min) Last dose: 2 days before surgery (skip 2 doses) Last dose: 3 days before surgery (skip 4 doses) 
    t1/2 = 16-18 h Moderate impairment (CrCl 30-50 mL/min) Last dose: 3 days before surgery (skip 4 doses) Last dose: 4-5 days before surgery (skip 6-8 doses) 
Rivaroxaban (20 mg once daily)    
    t1/2 = 8-9 h Normal or mild impairment (CrCl > 50 mL/min) Last dose: 2 days before surgery (skip 1 dose) Last dose: 3 days before surgery (skip 2 doses) 
    t1/2 = 9 h moderate impairment (CrCl 30-50 mL/min) Last dose: 2 days before surgery (skip 1 dose) Last dose: 3 days before surgery (skip 2 doses) 
    t1/2 = 9-10 h Severe impairment§ (CrCl 15-29.9 mL/min) Last dose: 3 days before surgery (skip 2 doses) Last dose: 4 days before surgery (skip 3 doses) 
Apixaban (5 mg twice daily)    
    t1/2 = 7-8 h Normal or mild impairment (CrCl > 50 mL/min) Last dose: 2 days before surgery (skip 2 doses) Last dose: 3 days before surgery (skip 4 doses) 
    t1/2 = 17-18 h Moderate impairment (CrCl 30-50 mL/min) Last dose: 3 days before surgery (skip 4 doses) Last dose: 4 days before surgery (skip 6 doses) 
Drug (dose)*Patient renal functionLow bleeding risk surgery† (2 or 3 drug half-lives between last dose and surgery)High bleeding risk surgery‡ (4 or 5 drug half-lives between last dose and surgery)
Dabigatran (150 mg twice daily)    
    t1/2 = 14-17 h Normal or mild impairment (CrCl > 50 mL/min) Last dose: 2 days before surgery (skip 2 doses) Last dose: 3 days before surgery (skip 4 doses) 
    t1/2 = 16-18 h Moderate impairment (CrCl 30-50 mL/min) Last dose: 3 days before surgery (skip 4 doses) Last dose: 4-5 days before surgery (skip 6-8 doses) 
Rivaroxaban (20 mg once daily)    
    t1/2 = 8-9 h Normal or mild impairment (CrCl > 50 mL/min) Last dose: 2 days before surgery (skip 1 dose) Last dose: 3 days before surgery (skip 2 doses) 
    t1/2 = 9 h moderate impairment (CrCl 30-50 mL/min) Last dose: 2 days before surgery (skip 1 dose) Last dose: 3 days before surgery (skip 2 doses) 
    t1/2 = 9-10 h Severe impairment§ (CrCl 15-29.9 mL/min) Last dose: 3 days before surgery (skip 2 doses) Last dose: 4 days before surgery (skip 3 doses) 
Apixaban (5 mg twice daily)    
    t1/2 = 7-8 h Normal or mild impairment (CrCl > 50 mL/min) Last dose: 2 days before surgery (skip 2 doses) Last dose: 3 days before surgery (skip 4 doses) 
    t1/2 = 17-18 h Moderate impairment (CrCl 30-50 mL/min) Last dose: 3 days before surgery (skip 4 doses) Last dose: 4 days before surgery (skip 6 doses) 
*

Estimated t1/2 based on renal clearance.

†

Aiming for mild to moderate residual anticoagulant effect at surgery (< 12%-25%).

‡

Aiming for no or minimal residual anticoagulant effect (< 3%-6%) at surgery.

§

Patients receiving rivaroxaban, 15 mg once daily.

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