G UIDELINES FOR THE P ERI -P ROCEDURAL M ANAGEMENT OF A DULTS T AKING T ARGET S PECIFIC A NTICOAGULANTS (TSOAC S ): DABIGATRAN, RIVAROXABAN, APIXABAN, EDOXABAN DrugRenal Function Low Procedural Bleed Risk (~2-3 half-lives between last dose & procedure) High Procedural Bleed Risk (~4-5 half-lives between last dose & procedure) Very High Procedural Bleed Risk (e.g., neuraxial, cardiothoracic, intracranial, spine) Resumption of TSOAC Low bleed risk procedures High / Very High bleed risk procedures Dabigatran (Pradaxa®) 75mg, 150mg BID CrCl > 50 mL/min t½=14-17h Interval between last dose and procedure: 48 hrs Last dose: 3 days prior Interval between last dose and procedure: 96 hrs Last dose: 5 days prior Interval between last dose and procedure: 120 hrs Last dose: 6 days prior May resume 24 hrs postop Very high thromboembolism risk:Resume no sooner than hrs postop Low/Int thromboembolism risk: resume no sooner than POD #5-7 Always discuss timing of resumption with proceduralist For neuraxial anesthesia: first dose no sooner than 6 hrs after catheter removal. See Neuraxial guidelines for details. Confirm that pre-op PTT or thrombin time is normal CrCl mL/min t½=16-18h Interval between last dose and procedure: 60 hrs Last dose: 3 days prior Interval between last dose and procedure: ≥ 96 hrs Last dose: ≥5 days prior Interval between last dose and procedure: >120 hrs Last dose: ≥ 6 days prior Confirm that pre-op PTT or thrombin time is normal Rivaroxaban (Xarelto®) 15mg daily- BID, 20mg daily CrCl > 30 mL/min t½=8-9h Interval between last dose and procedure: 24 hrs Last dose: 2 days prior Interval between last dose and procedure: 48 hrs Last dose: 3 days prior Interval between last dose and procedure: 72 hrs Last dose: 4 days prior CrCl mL/min t½=9-10h Interval between last dose and procedure: 48 hrs Last dose: 3 days prior Interval between last dose and procedure: 72 hrs Last dose: 4 days prior Interval between last dose and procedure: 120 hrs Last dose: 6 days prior Apixaban (Eliquis®) 2.5mg, 5mg, 10mg BID CrCl > 50 mL/min t½=7-8h Interval between last dose and procedure: 24 hrs Last dose: 2 days prior Interval between last dose and procedure: 48 hrs Last dose: 3 days prior Interval between last dose and procedure: 72 hrs Last dose: 4 days prior CrCl mL/min t½=17-18h Interval between last dose and procedure: 48 hrs Last dose: 3 days prior Interval between last dose and procedure: 96 hrs Last dose: 5 days prior Interval between last dose and procedure: 120 hrs Last dose: 6 days prior Edoxaban (Savaysa®) 30mg, 60mg daily CrCl > 50 mL/min t½=9-14h Interval between last dose and procedure: 36 hrs Last dose: 2 days prior Interval between last dose and procedure: 48 hrs Last dose: 3 days prior Interval between last dose and procedure: 72 hrs Last dose: 4 days prior

*HEART VALVES: Do not use TSOACS for mechanical heart valves. Procedures off anticoagulation Examples Invasive cardiac procedures (such as heart valve replacement, coronary artery bypass graft) Neurosurgical /neuraxial procedures Major surgery with significant tissue injury (such as orthopedic, abdominal) Certain interventional radiologic or endoscopic procedures with biopsy Higher risk urologic procedures: TURP, prostate biopsy, lithotripsy, prostatectomy, bladder surgery Procedures potentially safe on anticoagulation Examples Endoscopic or urologic procedures without biopsy Skin biopsy Potentially bloodless surgery (e.g, cataract).Consider risk of anesthesia administration (e.g., retrobulbar administration) Simple dental procedures such as cleaning,extractions, endodontics High Thrombotic Risk AFIB: CHADS 2 5-6, TIA/CVA<3 mo, VTE: VTE within 3 mo severe thrombophilia (deficiency of protein C, protein S, ATIII, APLA, or multiple abnormalities), recurrent VTE while ON anticoagulation Interrupt TSOAC Bridging anticoagulation NOT recommended. Patients may benefit from expert consultation to help weigh risk of thrombosis vs. bleed. Don’t Interrupt TSOAC Moderate Thrombotic Risk AFIB: CHADS VTE: VTE within 3-12 mo, recurrent VTE, non-severe thrombophilia (heterozygous factor V Leiden, PT20210 mutation), or active cancer Interrupt TSOAC Bridging anticoagulation NOT recommended. Expert consultation if complex patient or if there are questions Low Thrombotic Risk AFIB: CHADS & no prior TIA/CVA VTE: VTE > 12 mo with no other risk factors NOTES: these are general recommendations and not intended to replace clinician judgment. Individual patient risk profiles, procedure risk, and provider/patient preference may influence recommendations. See “UCSF Guidelines for the use of antithrombotic agents in the setting of neuraxial procedures” for additional information on neuraxial anesthesia Clearance of anticoagulant effect depends on renal function--reassess renal function within one month of pre-op planning Full anticoagulant effect occurs within hours of resuming TSOAC therapy. Patient must be tolerating orals and have good absorption. Post-procedure resumption of anticoagulation should be done with the approval of the proceduralist. Bridging with parenteral anticoagulants is NOT usually recommended for patients on TSOACs. However, bridging can be considered in patients at VERY high risk of thrombosis or with prolonged TSOAC hold times. Consultation with a specialist is recommended in complex situations. UCSF: Hematology Consult ( ) or Anticoagulation Clinic. SFGH: Anticoagulation Pharmacist ( ). VA: Anticoagulation Service (Refer to on-call schedule) References 1. Management of Anticoagulants in the Peri-Procedural Period. New York State’s QIO/Centers for Medicare & Medicaid Services document, American Society of Regional Anesthesia and Pain Medicine, Anticoagulation 3 rd Edition Guidelines (2010) and Interim Update Version 1.0 developed by Margaret Fang, MD, Steven Kayser, PharmD, Tracy Minichiello, MD, Christina S. Wang, PharmD. Approved by UCSF P&T xx.2015