DOAC Perioperative Management: Hold, Restart, and Neuraxial Rules
Scope: apixaban, rivaroxaban, edoxaban, dabigatran. Use a conservative, renal-aware approach and never bridge DOACs.
Baseline approach
- Bleeding risk drives timing: high-risk or neuraxial contexts use longer holds/restarts than low/mod risk.
- Dabigatran is renal-tiered: longer holds with lower CrCl (e.g., <30 mL/min → extended holds; consider avoiding elective neuraxial).
- Apixaban/Rivaroxaban/Edoxaban: escalate holds conservatively with impaired renal function (e.g., apixaban CrCl <25; rivaroxaban/edoxaban CrCl <30 → caution/avoid neuraxial).
Neuraxial hard-stops & catheter gating
- Hard-stops: avoid neuraxial if dabigatran CrCl <30; apixaban CrCl <25; rivaroxaban/edoxaban CrCl <30.
- Catheter in place: no DOAC dosing while present. Earliest restart is the **later of** baseline window vs removal + 24 h.
Bridging
Do NOT bridge DOACs. If “very high” thrombosis risk, consult Hematology for rare exceptions rather than auto-bridging.
For patient-specific timestamps and renal/catheter gating, use the AnticoagPlanner calculator.
Sources
- MD Anderson. Peri-Procedure Anticoagulants, V8 (approved 07/15/2025). DOAC tables/appendix.
- ASRA/Stanford institutional neuraxial catheter timing summaries.
Disclaimer: Educational content. Supports, not replaces, clinical judgment. Confirm local policy and anesthesia guidance for neuraxial catheters.