Management of antithrombotic agents or thrombocytopenia during oncology procedures: ISTH guideline

Based on the literature review and expert opinions, the panel proposes the below guidance statements:

Guidance for antithrombotic agents

• It is recommended that clinicians be aware of the presence of anticoagulants and/or antiplatelet agents prior to any procedures and obtain results of appropriate blood work if required.
• An assessment for risk and benefit ratio is recommended prior to each procedure
• In patients with low risk of thrombosis, the authors suggest withholding anticoagulation and/or antiplatelet agents prior to procedures.
• In all other patients (no to low risk of thrombosis), the authors recommend evaluating the bleeding risks of procedures as below
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The following management us suggested for procedures considered as low risk of bleeding: core biopsy (not deep tissue/organ), FNA, bone marrow biopsy, diagnostic or therapeutic draining procedures, or central line insertion (at compressible sites):
• ASA can be continued if monotherapy.
• For other antiplatelet agents and/or anticoagulation, there are limited data to guide practice, but it is generally considered safe to continue monotherapy.
• Other precautions can be taken to reduce the bleeding risk when AT agents are continued, such as ensuring INR <3 when warfarin is continued, delay morning dose of DOAC until after procedure.
Interruption of respective anticoagulants or antiplatelet agents (except for ASA) is suggested for procedures considered as moderate risk of bleeding: biopsy of deep tissue/organ, placement of an implantable port, a central venous catheter in a non-compressible site or a tunneled catheter, and/or large-bore drains.
In patients with suspected or known MPN undergoing bone marrow biopsy, particularly in the setting of extreme thrombocytosis (>1000 x 109/L), evaluation for acquired von Willebrand disease is suggested and, if present, steps to minimize hemorrhage risk.
For procedures associated with high risk of morbidity from bleeding events such as neuraxial procedures, withholding anticoagulation, and antiplatelet agents is suggested.
The following duration of interruption is suggested when anticoagulation or antiplatelet agents are held
• Warfarin: 5 days
• LMWH: 24 h in patients with normal kidney function
• DOACs: 2 days before a high-bleed-risk and 1 day before a low/moderate-bleed-risk (4 days if taking dabigatran and CrCl <50 ml/min) procedure
• In patients with CrCl <30 ml/min, longer interruption time will be needed for LMWH and DOACs
• ASA and clopidogrel: 5–7 days; prasugrel: 7–10 days; ticagrelor (reversible P2Y12 inhibitor): 3–5 days
For combined antiplatelet and anticoagulation therapies, the authors suggest limiting exposure to a single antithrombotic agent whenever possible peri-operatively, as combined therapies exacerbate risks of hemorrhage with surgical procedures.

• For lower bleeding risk procedures (such as FNA or insertion of central lines in compressible areas), a platelet count ≥20 x 109/L is suggested.
• For bone marrow biopsy, a specific target platelet threshold is not suggested.
• For procedures associated with higher risk of bleeding, including biopsies of deep tissues/organs such as percutaneous liver, kidney, transbronchial biopsies, insertion of tunneled catheters and implantable ports or to non-compressible access sites, or neuraxial procedures, the authors suggest a goal platelet count of ≥50 x 109/L, if feasible.