Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants

Abstract

Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient's interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.

Figure 1

Proposed algorithm for peri-operative management of non-vitamin K antagonist oral anticoagulants. CrCl, creatinine clearance; LMWH, low molecular weight heparin; NA, not applicable; NOAC, non-vitamin K antagonist oral anticoagulant; PCC, prothrombin complex concentrate; TE, thromboembolism.