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
• 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.