Standardized preoperative DOAC Interruption Achieves Low Anticoagulant Levels, provides safety from blood loss: JAMA
Researchers have found in a cohort study that a standardized preoperative interruption protocol generally resulted in direct oral anticoagulant (DOAC) levels below 30 ng/mL in most patients undergoing surgery. However, patients receiving apixaban were more likely to have residual DOAC levels of 30 ng/mL or higher compared with other agents. Importantly, preoperative direct oral anticoagulant levels were not associated with increased intraoperative blood loss, supporting the overall safety of the current interruption protocol.
Before elective surgery, direct oral anticoagulants (DOACs) are discontinued following a standardized protocol. However, this could result in insufficient lowering of direct oral anticoagulant levels that could increase bleeding risk. A study was done to estimate the proportion of patients with elevated direct oral anticoagulant levels at the time of elective surgery, evaluate factors associated withdirect oral anticoagulant levels, and examine associated blood loss.
This cohort study (direct oral anticoagulant Level Prior to Incision [DALI]) assessed adult patients prescribed a direct oral anticoagulant (apixaban, dabigatran, or rivaroxaban) for any indication and at any dose, undergoing an elective procedure requiring direct oral anticoagulant interruption between May 27, 2018, and February 25, 2024, at 2 Dutch hospitals. Blood was drawn immediately before surgery to determine direct oral anticoagulant levels (by liquid chromatography–mass spectrometry). Proportions of preoperative direct oral anticoagulant levels of 30 ng/mL or higher and their 95% CIs were estimated, stratified by direct oral anticoagulant type and surgical bleeding risk. Factors associated with direct oral anticoagulant levels were identified through multivariable linear regression. Surgical blood loss and 30-day postoperative complications were described according to direct oral anticoagulant concentrations.
Results The study was terminated after including 257 patients (100 receiving apixaban, 100 receiving rivaroxaban, and 57 receiving dabigatran due to the slow inclusion rate of those receiving dabigatran; median [IQR] age, 72 [66-78] years; 173 male [67%]); 212 patients (82%) underwent a high bleeding-risk operation. Preprocedural direct oral anticoagulant levels were 30 ng/mL or higher in 7.6% (95% CI, 4.9%-11.6%) of patients. Dabigatran and rivaroxaban had similar proportions, whereas 13.1% (95% CI, 7.8%-21.2%) of patients treated with apixaban had levels of 30 ng/mL or higher.
Treatment with apixaban, decreased kidney function, and a shorter interruption time were associated with higher levels. Surgical blood loss (median [range], 0 [0-4250] mL) was not associated with direct oral anticoagulant levels. Twelve patients (4.7%; 95% CI, 2.7%-8.0%), who all had direct oral anticoagulants levels less than 30 ng/mL, experienced major bleeding.
In this cohort study, most patients following the current protocol had direct oral anticoagulant levels less than 30 ng/mL, although the proportion of patients with elevated levels was higher for apixaban. Preoperative direct oral anticoagulant levels were not associated with blood loss during surgery.
Reference:
Camilleri E, Shahbabai P, Rad M, et al. Direct Oral Anticoagulant Levels at Time of Elective Surgery. JAMA Netw Open. 2026;9(2):e2555875. doi:10.1001/jamanetworkopen.2025.55875
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