CHADS score of 5 or 6 Recent (within 3mo) stroke or TIA Rheumatic valvular heart disease CHADs score of 3 or 4

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1 LAMC Department of Pharmacy Services: ANTICOAGULATION: Surgical Intervention Table 1: Classification of Surgical interventions according to bleeding risk t required to discontinue anticoagulation Dental interventions Ophthalmology (e.g. Cataract) Endoscopy without surgery Superficial surgery (e.g. abscess incision) Interventions with LOW bleeding risk Cholecystectomy Abdominal hysterectomy Coronary angiography/percutaneous coronary intervention/electrophysiologic testing Pacemaker/cardiac defibrillator insertion Gastrointestinal endoscopy with /without biopsy, enteroscopy, biliary/pancreatic stent without sphincterotomy, endonosonography without aspiration Minor plastic surgery (carpal tunnel repair) Minor orthopedic surgery/arthrocopy Minor gynecologic surgery (dilation and curettage) Minor dental procedures (extractions) Minor skin procedures (cancer excision) Minor eye procedures (cataract) Interventions with HIGH bleeding risk Major cardiac surgery (heart valve replacement/coronary artery bypass grafting) Major neurosurgical procedures Major cancer surgery (head and neck/abdominal/thoracic) Major orthopedic surgery (joint replacement/laminectomy) Major urologic surgery (prostate/bladder resection) Major vascular surgery Kidney biopsy Polypectomy, variceal treatment, biliary sphincterectomy, pneumatic dilatation Endoscopically guided fine-needle aspiration Any major operation (procedure duration>45 minutes) Table 2: stratification strategy for perioperative thromboembolism (adapted from Douketis et al) Indication for anticoagulant therapy for thrombotic events Mechanical heart valve Atrial Fibrillation VTE High Moderate Any mitral valve prosthesis Recent (within 6 mo) stroke or TIA Bileaflet aortic valve prosthesis and > 1 of the following risk factors: atrial fib, prior storke or TIA, hypertension, diabetes, CHF, age>75 CHADS score of 5 or 6 Recent (within 3mo) stroke or TIA Rheumatic valvular heart disease CHADs score of 3 or 4 Recent (within 3mo) VTE Severe thrombophilia VTE within the past 3-12 mo Recurrent VTE Active cancer (treated) within 6 mo or palliative) nsevere thrombophilia

2 Low Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke CHADS score of 0-2 VTE> 12mo previous and no other risk factors Table 3: Perioperative and Postoperative management of anticoagulation therapy on ELECTIVE Surgery/Procedure Medication T1/2 PERI-OP (Stop before surgical Need Bridging? for thromboemobolism? POST-OP (Restart after surgical Low Bleeding High Bleeding Low High Low Bleeding High Bleeding hours 24 hours 48 hrs (normal Crcl>50ml/min Crcl>50 ml/min (rapid onset, 2-3 hours) renal) 96 hrs 28 hours Crcl 31-50ml/min Crcl 31-50ml/min (severe 96 hours 144 hours renal) Crcl <30ml/min Dabigatran (Pradaxa) Apixaban (Eliquis) Rivaroxaban (Xeralto) Warfarin hours 9-12 hours 24 hours 9-12 hours 24 hours Do not stop 96 hours 96 hours Stop on preprocedure day 5 (PPD) PPD Instruction Low risk NO Use VTE Prophylaxis High risk Yes Pre-procedure day (PPD) PPD Instruction 12 to 24 hours (evening after the surgery) 5 Stop 1 INR If INR> 1.5 Give Vit K 1 to 2mg PO DAY 0 (surgery/ Procedure) on evening after surgery 5 Stop 3 Bridge LMWH 1 Last dose LMWH Day 0 (srgery) warfarin in the evening LMWH at (use approp. VTE prophylaxis)

3 Medication T1/2 PERI-OP (Stop before surgical Need Bridging? for thromboemobolism? POST-OP (Restart after surgical Low Bleeding High Bleeding Low High Low Bleeding High Bleeding Enoxaparin (Lovenox) 3-6 hours 24 hours ½ usual total daily dose 24 hours prior to surgery (2012 ACCP Guidelines) 24 hours Insertion and removal of a catheter for neuraxial anesthesia: (American Society of Regional Anesthesia) Time before catheter insertion Time wait from catheter removal time Low dose = 24 hours Low dose =6-8 hrs (e.g. 40mg daily or 30mg BID) High dose = 24 hours High dose = 24 hours (e.g. 1mg/kg BID) Unfractionated 45 min 4-5 hours 4-5 hrs 24 hrs hours Heparin URGENT surgical intervention: Discontinue newer oral anticoagulants If possible, wait until at least 12 hours and ideally 24 hours after the last dose If surgery cannot be delayed, the risk of bleeding will be increased and should be weighed against the urgency of the intervention Table 4: Antiplatelet agents: relevant information for perioperative & post-op management of antiplatelet agents Medication Time to maximum level T1/2 PERI-OP (Stop before surgical HIGH RISK ONLY Aspirin min min 4 days ** (consult cardiologist) Clopidogrel (Plavix) 1 hr circulating drug 8 hours 7-10 days 3-7 d for max antiplatelet effect Ticiopidine (Ticlid) 1-3 hours hrs 5-7 days Prasugrel (Effient) 30 min 7 hours 5-7 days Ticagrelor (Brilinta) 1.5 hours 7 hours 5-7 days POST-OP (Restart after surgical Intervention) 12 to 24 hours Clopidogrel with 300mg loading dose

4 Table 5: Conversion Strategies: NOACs = New Oral Anticoagulants: Dabigatran, Apixaban, Rivaroxaban Medication Strategy Warfarin to NOACs INR<2: Initiate immediately INR 2-2.5: Initiate immediately or better the next day INR>2.5 consult pharmacist NOACs to Warfarin Administer NOAC and warfarin concomitantly until the INR is in a range that is considered appropriate (warfarin may take 5-10 days for onset of action) NOTE: NOAC may have an additional impact on INR Measure INR just before the next intake of NOAC during concomitant administration Re test INR 24 hour after the last dose of NOAC Closely monitor INR within the first month until stable value attained Unfractionated heparin(ufh) to Initiate once IV Heparin is discontinued NOACs LMWH to NOACs Initiate NOACs when the next dose of LMWH would have been foreseen NOACs to LMWH Initiate when the next dose of NOAC is due NOACs to NOACs Initiate when the next dose is due; caution with impaired renal function Aspirin or clopidogrel to NOACs Initiate immediately after aspirin or clopidogrel stopped unless combination therapy is deemed necessary despite the increased bleeding risk Table 5: Dosing Errors: NOACs=New Oral Anticoagulants: Dabigatran, Apixaban, Rivaroxaban Dosing Missed Dose Double Dose Uncertainty about dose intake Frequency BID Take the forgotten dose up till 6 hours after the scheduled intake; otherwise skip the dose and the next scheduled dose should be taken Forgo the next planned dose; restart bid intake from after 24 hours Daily Take a forgotten dose up till 12 Continue the normal dosing hours after the scheduled intake; regimen i.e. without skipping the Otherwise skip the dose and next next daily dose scheduled dose should be taken Continue the planned dose regimen, starting the next dose at 12 hour interval Take another pill and then continue the planned dose regimen

5 References: Chassot, Pierre Guy. Perioperative Antiplatelet Therapy. Aafp.org/afp/2010/1215/pl484.html. Heidbuchel Hein. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with nonvalvular atrial fibrillation. Europace (2013) dol: /europace/eut083. Ortel.Thomas. Perioperative management of patients on chronic antithrombotic therapy. Blood.6 december 2012.volume 120. Number 24. Lip, Gregory YH. Management of anticoagulation before and after elective surgery. UpToDate 10/31/2013. Hunter,Melissa.Management of Rivaroxaban in Adults. UNC Health Care Guideline.May Nutescu,Edith.New approaches to reversing oral anticoagulant therapy. AJHP volume70.number10.supplement1.may 15,2013. Kaatz,Scott. Update in bridging anticoagulation. J Thromb Thrombolysis (2011) 31: Sypropoulos,Alex. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood,11 October 2012.Volume120.Number15.

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