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Managing patients taking anticoagulants and antiplatelets prior to minor procedures and surgery

I always get asked by dentists and sometimes patients when to stop anti-platelets, e.g. aspirin, or anticoagulants prior to procedures, e.g. dental extractions and joint replacements.

I understand the situation depends on the patient’s medical condition as well as the planned procedure, however, I would really appreciate if you could give me a resource or publication to look at and understand more about this subject?

Dr Frat Yousif

Response from the bpacnz editorial team:

As the correspondent suggests, the planned procedure and the patient’s medical condition(s) heavily influence whether an antithrombotic should be stopped prior to surgery. Ultimately, this decision should be individualised; weighing the added risk and consequences of bleeding (Table 1) against the risk of experiencing a thromboembolic event if treatment is stopped, and taking into consideration the patient’s medical history.1,2 In clinical scenarios involving patients with a significant cardiac history or high-risk procedures, consultation with the cardiologist, surgeon and anaesthesiologist is also likely to be necessary.2

Table 1. Risk of bleeding associated with invasive surgical procedures1

Minimal risk Low risk High risk
  • Minor dermatological procedures e.g. removal of basal or squamous carcinomas or premalignant lesions
  • Minor dental procedures e.g. dental extractions, restorations, prosthetics or endodontics
  • Cataract procedures
  • Abdominal hernia repair or hysterectomy
  • Arthroscopy
  • Bronchoscopy, including biopsy
  • Coronary angiography
  • Cutaneous or lymph node biopsy
  • Epidural injections with INR < 1.2
  • Gastrointestinal endoscopy, including biopsy
  • Haemorrhoid removal
  • Laparoscopic cholecystectomy
  • Pacemaker or cardioverter defibrillator implantation (although withholding DOAC is still recommended)
  • Surgery of the hand, foot or shoulder
  • Any major operation lasting more than 45 minutes
  • Bowel resection
  • Cancer surgery
  • Cardiac surgery
  • Intracranial or spinal surgery
  • Colonic polyp resection (≥ 1 cm)
  • Gastrointestinal surgery
  • Major surgery with extensive tissue damage
  • Major orthopaedic surgery
  • Nephrectomy or kidney biopsy
  • Reconstructive plastic surgery
  • Surgery in highly vascular areas e.g. kidneys, liver and spleen
  • Urological surgery

Publications by Keeling et al3 and Armstrong et al4 provide recommendations based on the bleeding risk of a procedure and type of antithrombotic used. Overall, evidence suggests that many minor procedures can be performed in primary care without stopping the patient’s normal regimen (e.g. most minor dermatological procedures).3,4 In addition, continued treatment is likely suitable during some minimally invasive surgeries performed in secondary care, such as cataracts, joint injections and pacemaker insertion.4 For other procedures, however, the guidance is not as clear cut. For example, in hip fracture surgery patients may continue an antiplatelet, although anticoagulation should generally be stopped.5

The American Dental Association (ADA)6 provides guidance specific to dental procedures and indicates there is strong evidence for continuing “older” anticoagulants (e.g. warfarin) and antiplatelets (e.g. aspirin, clopidogrel, ticagrelor) during both minor procedures and invasive dental surgeries (e.g. oral tumour removal). There is also limited evidence that direct oral anticoagulants (DOACs; e.g. dabigatran, rivaroxaban) can be continued, however, the ADA acknowledges that there is “no direct evidence from prospective trials comparing different periprocedural management strategies” for these medicines.6

If the risk of bleeding is considered too great and a decision for withdrawal is made, the timing of the last dose depends on the half-life of the medicine and, for DOACs, the patient’s renal function.1,2 Table 2 provides recommendations on when to stop various antithrombotics before surgery based on information from Hornor et al2 and PHARMAC/bpacnz bleeding management guidelines.1 Following surgery, the decision on when to restart treatment should be patient-specific and only considered once the risk of bleeding is minimal.2

Table 2. Recommendations for stopping antithrombotics prior to surgery1,2

Medicine Estimated Half-life Renal function (based on creatinine clearance; mL/min) Last dose before surgery
Aspirin 3-10 hours No specific recommendations for stopping prior to surgery based on renal function 7 days
Clopidogrel 8 hours 5-7 days
Ticagrelor 9 hours 5-7 days
Warfarin* 20-60 hours 5 days
Dabigatran 12 hours for normal renal function; longer for renal impairment ≥ 80
≥ 50 to < 80
≥ 30 to < 50
< 30
1-2 days
1-3 days
2-4 days
Contraindicated
Rivaroxaban 5-9 hours for normal renal function; longer for renal impairment ≥ 50 to < 80
≥ 30 to < 50
< 30
1–3 days
2–3 days
Seek specialist advice

* In patients who stop warfarin for a procedure and remain at high thrombotic risk, “bridging” treatment with a low molecular weight heparin or unfractionated heparin may be necessary.2

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