Managing bleeding risk
|
Reported risk |
Recommended management |
|
Haemorrhage |
Stop DOAC and refer patient immediately to A&E if serious bleeding occurs eg GI-bleeding, epistaxis lasting more than 1 hr |
| Serious Trauma (especially to the head) | Withhold DOAC and refer to A&E |
| Unexplained acute drop in Hb or BP | Withhold DOAC and refer for urgent investigations |
| Excessive bruising | Seek urgent specialist advice |
Management of DOAC around elective MINOR procedures
Examples of MINOR PROCEDURES that are considered to carry no clinically important bleeding risk and /or where adequate local haemostasis is possible
- Dental interventions: e.g. tooth extraction (1-3 teeth), root canal procedures, incision of abscess, implant positioning, periodontal surgery
- Superficial surgery e.g. abscess incision, small dermatologic excisions etc
- Ophthalmology: cataract or glaucoma intervention
- If estimated CrCL <30mL/min: discuss with local haematologist
| DOAC | Day before procedue | Day of procedure | Day after procedure |
| Apixaban BD | Take AM and PM doses | No DOAC | Restart AM |
| Dabigatran BD | Take AM omit PM dose | No DOAC | Resatrt AM |
| Rivaroxaban OD | If usually takes AM, take dose, If usually takes PM, then take dose no later than 6pm (schedule procedure ~18-24h post dose) | No DOAC | If usually takes AM, restrat AM, If usually takes PM, restart PM |
| Edoxaban OD | If usually takes AM, take dose, If usually takes PM, then take dose no later than 6pm (schedule procedure ~18-24h post dose) | No DOAC | If usually takes AM, restrat AM, If usually takes PM, restart PM |
Post-procedure
- Optimise local haemostasis
- Delay restarting DOAC if there are any concerns re bleeding; discuss with local haematologist as appropriate
- Peak drug levels (i.e. therapeutic anticoagulation) are reached 2-4 hours post oral dose
For more complex procedures
These are associated with higher bleeding risks e.g. in-patient procedures (including day surgery) or major surgery: management plans should be arranged by the pre-assessment clinic or the responsible speciality team of the trust where the procedure will be undertaken. These patients will need to be assessed in terms of thrombosis and bleeding risk and DOAC withheld as per local secondary care guidelines.
