Peri-Operative Management of Anti-thrombotics (antiplatelets, anticoagulants)

Adapted from Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures Todd H. Baron, M.D., Patrick S. Kamath, M.D., and Robert D. McBane, M.D. N Engl J Med 2013; 368:2113-2124

Agent MOA Peri-Procedural Management Labs Reversal
Anticoagulants
Warfarin inhibits Vit K dependent factors: 2,7,9,10 and Protein C and S hold 1-8 days, until INR <=1.5, this happens within 5 days for 93% of patients INR Oral or IV Vitamin K, +/- FFP, prothrombin complex concentrate (PCC) 4 factor preferred over 3
Unfractionated Heparin Antithrombin activation (inhibits 2a, 9a, 10x, 11a, 12a) IV 2-6hrs depending on dose, SubQ 12-24 hrs depend. on dose aPTT Protamine sulfate
LMW Heparins (enoxaparin = lovenox; dalteparin (fragmin)) antithrombin activation (inhibits Xa, some 2a) 24hr None – perhaps anti-Xa Ab Protamine (only partial)

Also note CKD>Stage 4 impairs elimination

Fondaparinux Antithrombin activation (Xa inhibitor) 36-48hr none, consider fondaparinux-specific anti-Xa assays none, perhaps F7a in high risk major bleed
Dabigatran (pradaxa; argatroban maybe same) direct thrombin inhibitor 1-2 days if crcl>50, otherwise 3-5days aPTT or thrombin time None, perhaps F8 inhibitor bypass activity or recomb activated 7a or dialysis
Rivaroxaban (BAM the Xa) direct Xa inhibitor >1 day in nomral renal fx, 2 d cr cl 60-90, 3d crcl 30-59, 4d crcl 15-29 ptt or anti-Xa ab none, consider PCCs
Apixaban (eliquis) Direct Xa inhibitor 1-2d crcl>60, 3d crcl 50-59, 5d cr cl <49 anti-Xa ab non, consider charcoal hemoperfusion or PCCs (4 factor best)
Desirudin (iprivask) Direct thrombin inhibitor 2hr aPTT, thrombin time, or ecarin clotting time none
Antiplatelets
Aspirin COX inhibitor – irreversible 7-10 days non, consider platelet function tests (TEG?) Platelet transfusion
ASA + Dipyridamole Phosphodiesterase inhibitor 7-10 days None, but consider platelet function testing Platelet transfusion
Cilostazol Phosphodiesterase inhibitor 2 days None Platelet transfusion
Thienopyridine agents (clopidogrel – plavix; ticlopidine, prasugrel – effient; ticagrelor – brilinta) ADP receptor antagonist 5 days None, but consider platelet function testing Consider platelet transfusion, but limited efficacy
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