Periprocedural Management of Patients on Anticoagulation DATE: November 2, 2018 PRESENTED BY: Bethany Samuelson Bannow, Assistant Professor, Hematology

Objectives  Describe the periprocedural management of oral anticoagulants  Describe the periprocedural management of parenteral anticoagulants Describe management of procedure-related bleeding in the anticoagulated patient

Oral Anticoagulants Warfarin Apixaban Direct thrombin inhibitor Rivaroxaban Dabigatran Edoxaban Anti-Xa drugs

Warfarin Anticoagulant effect measured with INR Onset 24-72 hours (including dose changes) ~5 days to normalize INR Vitamin K can reverse more rapidly Bridging rarely recommended

Bridging LMWH or unfractionated heparin Indications Recent VTE or recurrent VTE with APLS A fib + CVA within 3 months Mitral or tricuspid prosthesis Caged-ball/tilting disc aortic valve Bileaflet aortic prosthesis + additional risk

DOACs Recommendations depend on drug-, procedure- and patient-specific features Low-risk procedures may require omission of 0-2 doses High-risk procedures may require omission of 2-6 doses

DOACs Low risk procedures High-risk procedures Non-tunneled venous access TIPSS Organ biopsies Thoracentesis/paracentesis Tunneled lines Embolizations IVC filters Spine/CNS procedures

Direct Thrombin Inhibitor Dabigatran BID dosing, t½ = 12-17 hours Thrombin time sensitive Hold 24-48 hours (longer if CrCl <80) Urgent/emergent reversal: idarucizumab

Xa Inhibitors Apixaban BID dosing t½ = 12 hours Anti-Xa best measurement Hold 24-48 hours (longer if CrCl <50) Least renally cleared Awaiting availability of andexanet for reversal

Xa Inhibitors Rivaroxaban Daily dosing t½ = 8-10 hours Anti-Xa best measurement Hold 24-48 hours (longer if acute renal failure) Awaiting availability of andexanet for reversal

Xa Inhibitors Edoxaban Daily dosing t½ = 10-14 hours Anti-Xa best measurement Hold 24-48 hours (longer if CrCl <30ml/min) Awaiting availability of andexanet for reversal

Parenteral Anticoagulants Unfractionated heparin Low molecular weight heparin Enoxaparin Dalteparin Fondaparinux Argatroban

Unfractionated Heparin Therapeutic dosing continuous infusion t½ = 1.5 hours PTT standard – anti-Xa alternative Stop ~ 6 hours pre-procedure Reverse with protamine (100%)

LMWH Enoxaparin SubQ daily to BID, t½ = 4.5-7 hours Anti-Xa for measurement Hold 24 hours pre-procedure Reverse with protamine (60%)

LMWH Dalteparin SubQ daily, t½ = 3-5 hours Anti-Xa for measurement Hold 24 hours pre-procedure Reverse with protamine (60%)

Fondaparinux SubQ daily, t½ = 17-21 hours Anti-Xa (not typically done) Hold 5 days pre-procedure No specific reversal agent Often use rFVIIa

Argatroban Continuous infusion, t½ = 39-51 minutes PTT for measurement Stop ~ 3 hours pre-procedure No reversal (short half-life)

Procedure-Related Bleeding Local hemostasis Supportive care Tincture of time Reversal

Pitfalls of Reversal Available but complex Often incomplete (LWMH, Xa inhibitors, etc) Often nonspecific (PCC, rFVIIa, protamine for LMWH) Increased risk of thrombosis May be helpful but do not replace local hemostasis

Take Home Anticoagulant management depends on: The patient’s risk of thrombosis The bleeding risk of the procedure The Hemophilia Center 503-346-0640