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

2. 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

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

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

5. 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

6. 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

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

8. Direct Thrombin Inhibitor
Dabigatran
BID dosing, t½ = hours
Thrombin time sensitive
Hold hours (longer if CrCl <80)
Urgent/emergent reversal: idarucizumab

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

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

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

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

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

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

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

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

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

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

19. 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

20. Take Home Anticoagulant management depends on:
The patient’s risk of thrombosis
The bleeding risk of the procedure
The Hemophilia Center