Periprocedural Management With Antithrombotic Therapy Adult Inpatient Ambulatory Guideline 20201029

Effective 10-17-2019. Contact CCKM@uwhealth.org for previous versions.
Periprocedural Management with Antithrombotic

Therapy - Adult - Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click each header below to jump to the section of interest
Table of Contents
INTRODUCTION .................................................................................................................................3
SCOPE................................................................................................................................................3
DEFINITIONS ......................................................................................................................................3
RECOMMENDATIONS .........................................................................................................................3
METHODOLOGY .................................................................................................................................9
COLLATERAL TOOLS & RESOURCES ................................................................................................... 10
APPENDIX A. EXAMPLE 5-DAY HOLD BRIDGING PLAN ....................................................................... 11
APPENDIX B. DOSING OF PARENTERAL ANTICOAGULANTS FOR PERIPROCEDURAL MANAGEMENT .... 12
REFERENCES .................................................................................................................................... 13
Copyright © 2020 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org
CCKM@uwhealth.org Last Revised: 01/2020
Content Expert(s):
Name: Anne Rose, PharmD – Pharmacy
Phone Number: (608)-263-9738
Email Address: arose@uwhealth.org
Contact for Changes:

Name: Philip Trapskin, PharmD – Drug Policy Program
Phone Number: (608) 263-1328
Email Address: ptrapskin@uwhealth.org
Guideline Author(s):
Jennifer Fever, PharmD – Pharmacy
Anne Rose, PharmD – Pharmacy
Reviewer(s):
David Ciske, MD – Medical Director: Anticoagulation Clinic and Internal Medicine
Erin Robinson, PharmD, CACP – Anticoagulation Clinic
Patrick Pfau, MD – Gastroenterology
David Yang, MD – Laboratory
Committee Approval(s):
Inpatient Anticoagulation Committee: June 2019
Ambulatory Anticoagulation Committee: July 2019
Pharmacy & Therapeutics Committee
• Original: 2011
• Revisions: 2013; 2015; October 2019
Introduction
Patients receiving long term antithrombotic therapy who require surgery, or an invasive
procedure present a difficult therapeutic dilemma for clinicians. In this periprocedural interval
when antithrombotic therapy is halted, periprocedural anticoagulation (bridging therapy) with a
heparin product may be recommended for some patients.1,2 There is new evidence to support
the use of bridging therapy in a small group of high-risk patients which has been outlined in this
guideline. Studies have shown an increase in bleeding events when bridging therapy with a
heparin agent was used both before and after procedures, with no difference in the incidence of
thromboembolic events, compared to patients who did not receive bridging therapy around the
time of procedures.3,4
Scope
Intended User(s):
• Physicians
• Advanced Practice Providers
• Pharmacists
• Nurses
Objective(s):
• To provide guidance on holding, bridging and resuming antithrombotic therapy for
planned procedures
Target Population: Inpatient and ambulatory adult patients who have indication(s) for
antithrombotic medications and require antithrombotic therapy held for a planned surgical
procedure
Clinical Questions Considered:

• What patient population requires bridging of antithrombotic therapy for procedures?
• When should antithrombotic therapy be resumed post procedure?
Definitions
1. Periprocedural or Bridging Anticoagulation – administration of a short acting anticoagulant

during the interruption of long-term antithrombotic therapy for major/minor surgery or
procedures. Usually administered for a 10 to 12-day period.1
2. Periprocedural – the period of time prior to, during and following an invasive procedure
3. Antithrombotic therapy – includes any anticoagulant or antiplatelet medication
Recommendations
Periprocedural Antithrombotic Management
1. Weigh the consequences of short-term risk for thromboembolism and bleeding for the
individual patient.1
1.1. Very few patients will need periprocedural anticoagulation or bridging therapy3,4
(UW Health GRADE moderate quality evidence, strong recommendation).
3
1.2. Overall risk stratification should focus on the patient's risk of thromboembolism since the
consequences of a thromboembolic event are more likely to have serious, lasting effects
than compared to consequences of major bleeding.1,2 (UW Health low quality evidence,
weak/conditional recommendation)
1.3. Use Table 1 to evaluate the bleeding risk of procedure or surgery1 (UW Health GRADE
moderate quality evidence, weak/conditional recommendation)
1.4. Use Table 2 to identify patients at risk for systemic embolism if antithrombotic agent is
discontinued1-4 (UW Health GRADE moderate quality evidence, strong recommendation)
1.4.1. It is recommended to use periprocedural (bridge) therapy for patients identified in
Table 2.1-4 (UW Health GRADE moderate quality evidence, strong
recommendation)
1.5. Endoscopic procedures
1.5.1. For low thromboembolic risk patients: hold warfarin and proceed with endoscopic
procedure when the INR < 1.5 and for other anticoagulants see specific
recommendations in Tables 4-8.1,5,6 (UW Health low quality evidence,
1.5.2. For high thromboembolic risk patients: see Table 3. Hold anticoagulation based on
specific recommendations for each drug listed in Tables 4-8.1,5,6 (UW Health low
quality evidence, weak/conditional recommendation)
Table 1. Bleeding Risk for Surgery/Procedure1,6,7 (UW Health moderate quality evidence;
High Bleed Risk Moderate Bleed Risk Low Bleed Risk
• Any procedure using • Ablation (musculoskeletal) • Cataract surgery
cardiopulmonary bypass or • Breast procedures (biopsy) • Dental procedures:
mechanical assist device • Epidural injection -Dental hygiene
• Ablation (abdominal) • Facet injection - Simple extractions
• Bladder surgery • Fine needle aspiration of a solid - Restorations
• Bowel polypectomy organ - Endodontics
• Fine needle aspiration of deep • Interventional radiology - Prosthetics
tissue or peritoneal space procedures: • Cutaneous surgeries (most)
• Interventional radiology -Angio up to 7 french • Laparoscopic
procedures: -Venous interventions cholecystectomy or hernia
-Transjugular intrahepatic -Chemo/radioembolizations repair
portosystemic shunt (TIPS) -Uterine fibroid embolization • Coronary angiography
-New biliary tube -Tunneled venous catheter • Endoscopy with or without
-Transjugular liver biopsy placement biopsy
-Nephrostomy tube placement -Port • Colonoscopy with or without
-Radiofrequency ablation -Abscess drain biopsy
• Intracranial surgery -Percutaneous cholecystectomy • Joint aspirations and
• Major cancer surgery -Feeding tube insertion injections
• Major orthopedic surgery (hip or • Renal or lung biopsy • Interventional radiology
knee replacement) • Resection of colon polyps procedures:
• Paracentesis • Prostate biopsy -Catheter exchanges
• Peripheral artery bypass and • Pacemaker or defibrillator -Central line removal
other major vascular surgery implantation -Dialysis access
• Prostate surgery • Outpatient neurology procedures intervention
• Reconstructive plastic surgery • Major intraabdominal surgery -IVC filter placement
• Spinal surgery/Epidural procedure • Major intrathoracic surgery -Non-tunneled catheter
• More invasive dental or ophthalmic placement
procedures -Superficial aspirations
• Thoracentesis • Venography
• Vertebroplasty
Table 2. Periprocedural Risk for Thromboembolism 1,3,4,8 (UW Health moderate quality evidence;
strong recommendation)
Risk High:
Periprocedural Anticoagulation advised
Mechanical Heart • Any mechanical mitral valve
Valve • Older mechanical valve model (caged ball or tilting disc) in mitral or
aortic position
• Recently placed mechanical valve (< 3 months) in mitral or aortic
position
• Recent stroke or TIA (within 6 months) with mitral or aortic valve
Atrial Fibrillation • With mechanical heart valve in mitral or aortic position
• With recent stroke or TIA (within 3 months)
Venous • VTE within previous 3 months

Thromboembolism
Coagulopathies • Deficiency of protein C, protein S, or antithrombin
• Antiphospholipid antibody syndrome
• Multiple thrombophilic abnormalities
Table 3. Anticoagulation Considerations for Endoscopic Procedures 1,6,7 (UW Health low quality
evidence; weak/conditional recommendation)
Endoscopic Procedure High Thromboembolic Risk
Diagnostic or Screening Hold anticoagulation*
Determine if peri-procedural bridging is needed
Low biopsy risk Hold anticoagulation*
Removal of < 10 mm polyps with cold Determine if peri-procedural bridging is needed
snare or forceps
Large polyp removal (> 10 mm) Hold anticoagulation*
Determine if peri-procedural bridging is needed
Sphincterotomy Hold anticoagulation*

Esophageal Dilation Determine if peri-procedural bridging is needed
Fine Needle Aspiration
*See individual anticoagulant recommendations for holding prior to procedure
2. Warfarin1,7,8,9
2.1. Evaluate the INR at least 7 days before surgery or procedure to allow for planning
of perioperative management. Confirm target INR for specific procedure. (UW
Health moderate quality evidence, strong recommendation)
2.2. Warfarin may be continued during procedures where bleed risk is low.1,7 (UW
Health low quality evidence, weak/conditional recommendation)
2.2.1. Simple dental procedures (including extractions)
• If no oral prohemostatic agent is co-administered, then warfarin should
be held for 2-3 days before the procedure)
2.2.2. Cataract surgery
2.2.3. Diagnostic or screening colonoscopies
2.2.4. Some cutaneous surgeries
2.2.5. For endoscopic procedures – see Table 3
2.2.6. Low risk abdominal procedures
2.2.7. Joint aspirations or injections
2.3. Check INR within 24 hours of surgical procedure to ensure that INR goal has been
attained.1 (UW Health low quality evidence, strong recommendation)
2.4. If timing does not allow for gradual reduction of INR from withholding warfarin
alone, administration of phytonadione (vitamin K), fresh frozen plasma, or
prothrombin complex concentrates may be necessary. (UW Health moderate
quality evidence, strong recommendation)
2.5. Appendix A is an example of a bridging plan for warfarin
Table 4 Periprocedural planning for warfarin1,7,8,9 (UW Health low quality evidence,
Drug Pre-procedure Pre-Procedure Plan Post Procedure Plan
INR
Warfarin 2.0 – 3.0 Stop 5 days before procedure Start within 24 hours if approved by
proceduralist
3.0 – 4.5 Stop 6 days before procedure
> 4.5 Stop 6-7 days before procedure

Consider rechecking INR after 2-3
days of held doses
If indicated, consider phytonadione
3. Direct Oral Anticoagulants (DOACs)1,2,10,11,12,13 – Listed Alphabetically

3.1 Pre-operative parenteral anticoagulation (bridging) is not needed.
3.2 Evaluate renal function at least 7 days before surgery to allow for planning of
perioperative management. (UW Health low quality evidence, weak/conditional
recommendation)
3.3 DOACs may be continued during procedures where bleeding risk is low:
3.3.1 Low risk interventional radiology procedures (UW Health low quality
evidence, weak/conditional recommendation)
3.4 If timing does not allow for reversal of anticoagulant effect from withholding doses
alone, administration of procoagulant agents may be necessary. (UW Health low
quality evidence, weak/conditional recommendation)
3.5 Tables 5 and 6 provide recommendations for periprocedural management.
The PAUSE study was a prospective, cohort study evaluating the safety of a
standardized perioperative DOAC strategy in AF patients. The standardized
approach omitted DOACs 1 day prior to a low-bleeding risk procedure and 2 days
prior to a high-bleeding risk procedure. DOACs were resumed 1 day after a low-
bleeding risk procedure and 2 days after a high-bleeding risk procedure. Major
bleeding and arterial thromboembolism were tracked for 30 days post procedure.
Overall, major bleeding 30-day post-procedure for all was 1.35% for apixaban,
0.9% for dabigatran and 1.85% for rivaroxaban. Arterial thromboembolism was
0.16% for apixaban, 0.6% for dabigatran and 0.4% for rivaroxaban.
There were 33.5% of patients with a high-bleed risk procedure, Major bleeding
rates were 3% for apixaban and 3% for rivaroxaban. The PAUSE trial offers a
standardized approach to periprocedural planning for DOACs.14
Table 5 Periprocedural planning for direct oral anticoagulants14 (UW Health low quality evidence; weak/conditional
recommendation)
Drug Minor Surgery of Standard Bleed Major Surgery or High Bleed Risk
Risk Surgery Surgery
Apixaban Stop 1 day before procedure Stop 2 days before procedure
Dabigatran (CrCl > 50 mL/min) Stop 1 day before procedure Stop 2 days before procedure
Dabigatran (CrCl ≤ 50 mL/min) Stop 2 days before procedure Stop 4 days before procedure
Edoxaban Stop 1 day before procedure Stop 2 days before procedure
Rivaroxaban Stop 1 day before procedure Stop 2 days before procedure
Table 6 Post-procedural planning for the direct oral anticoagulants10,11,12,13 (UW Health low quality evidence,
Drug Minor surgery or Standard Major surgery or high Onset of
bleed risk surgery bleed risk surgery anticoagulation
Apixaban Start within 24 hours Start within 72 hours 3 – 5 hours
if approved by proceduralist if approved by
proceduralist
Dabigatran Start within 24 hours Start within 72 hours 2 hours
proceduralist
Edoxaban Start within 24 hours Start within 72 hours 2 hours
proceduralist
Rivaroxaban Start within 24 hours Start within 72 hours if 2 – 4 hours
if approved by proceduralist approved by proceduralist
4. Parenteral Anticoagulants1,7,9,15,16,17,18,19
4.1 Parenteral anticoagulation may be used for periprocedural anticoagulation
management (bridging) in certain high-risk patients.
4.2 If timing does not allow for reversal of anticoagulant effect from withholding doses
alone, administration of reversal agents or procoagulant agents may be necessary.
(UW Health low quality evidence, weak/conditional recommendation)
4.3 Tables 7 and 8 provide recommendations for periprocedural management
4.4 Appendix B provides dosing recommendations for parenteral anticoagulants when
used for bridging
Table 7 Periprocedural planning for parenteral anticoagulants15,16,17,18,19 (UW Health low quality evidence,
Drug Pre-procedure Any bleed risk surgery
Argatroban Normal hepatic function Stop 3 hours before procedure
Child-Pugh Score > 6 Stop 9 hours before procedure
Bivalirudin CrCl ≥ 30 mL/min Stop 1.5 hours before procedure

CrCl < 30 mL/min Stop 3 hours before procedure
Enoxaparin Prophylactic Dosing Stop 12 hours before procedure

Therapeutic Dosing Stop 24 hours before procedure
Fondaparinux CrCl ≥ 50 mL/min Stop 3 days before procedure

CrCl < 50 mL/min Stop 5 days before procedure
Unfractionated Heparin Prophylactic Dosing May give the morning before procedure
Therapeutic Dosing Stop 4-6 hours before procedure
7
Table 8 Post-procedural planning for parenteral anticoagulants15,16,17,18,19 (UW Health low quality evidence,
Drug Minor surgery or Standard Major surgery or high Onset of
bleed risk surgery bleed risk surgery anticoagulation
Argatroban Start within 12 hours Start within 24 hours 30 minutes
if approved by surgeon if approved by
proceduralist
Bivalirudin Start within 12 hours Start within 24 hours 15 minutes
proceduralist
Enoxaparin Start within 24 hours Start within 72 hours 3 – 5 hours
proceduralist
Fondaparinux Start within 24 hours Start within 72 hours if 3 hours
if approved by surgeon approved by surgeon
Unfractionated Start within 12 hours if Start within 24 hours Immediate
Heparin approved by surgeon if approved by
proceduralist
5. Antiplatelet Therapy1,20,21,22 – Listed Alphabetically

5.1 For periprocedural management of antiplatelet therapy, assess use at least 7 days before
surgery or procedure to allow for adequate hold time. (UW Health low quality evidence,
5.2 If timing does not allow for reversal of antiplatelet effect from withholding doses alone, the
surgeon may still elect to proceed with surgical procedure. (UW Health very low quality
evidence, weak/conditional recommendation)
5.2.1 Patients with coronary artery stent requiring surgery it is recommended to defer
surgery for at least 6 weeks after stent placement.1 (UW Health moderate quality
evidence, strong recommendation)
5.2.2 For inpatients the VerifyNow Platelet Reactivity laboratory tests may be used for
aspirin or clopidogrel to determine the level of platelet inhibition (UW Health low
quality evidence, weak/conditional recommendation
5.3 Table 9 provide recommendations for periprocedural management
Table 9 Periprocedural management for antiplatelet drugs1,20,21,22 (UW Health low quality evidence,
Drug Pre-Procedure Plan Post-Procedure Plan
Aspirin Stop 7-10 days before procedure Start within 24 hours
(low cardiovascular event risk) if approved by proceduralist
Aspirin May continue aspirin Start within 24 hours
(high cardiovascular event risk) if approved by proceduralist
Cangrelor Stop 1-6 hours before procedure Start within 24 hours if
approved by proceduralist
Clopidogrel Stop 5-7 days before procedure Start within 24-48 hours
if approved by proceduralist
Cilostazol Stop 1 -2 days before procedure Start within 24 hours
Dipyridamole Stop 1 -2 days before procedure Start within 24 hours
Prasugrel Stop 5-7 days before procedure Start within 24-48 hours
Ticagrelor Stop 5 days before procedure Start within 24-48 hours
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
Methodology
Development Process
Each guideline is reviewed and updated a minimum of every 3 years. All guidelines are
developed using the guiding principles, standard processes, and styling outlined in the UW
Health Clinical Practice Guideline Resource Guide. This includes expectations for workgroup
composition and recruitment strategies, disclosure and management of conflict of interest for
participating workgroup members, literature review techniques, evidence grading resources,
required approval bodies, and suggestions for communication and implementation.
Methods Used to Collect the Evidence:

The following criteria were used by the guideline author(s) and workgroup members to conduct
electronic database searches in the collection of evidence for review.
Literature Sources:
• Electronic database search (e.g., PubMed)
• Hand-searching journals, external guidelines, and conference publications
Time Period: 2000 to 2019
Search Terms:
• Term 1: Periprocedural AND anticoagulant
• Term 2: Periprocedural AND antiplatelet
Methods to Select the Evidence:

Original research, meta-analysis, reviews and guidance papers were included in the review.
Findings and recommendations derived from the included articles were discussed with guideline
authors when developing recommendations.
Methods Used to Formulate the Recommendations:

The workgroup members agreed to adopt recommendations developed by external
organizations and/or created recommendations internally via a consensus process using
discussion of the literature and expert experience/opinion. If issues or controversies arose
where consensus could not be reached, the topic was escalated appropriately per the guiding
principles outlined in the UW Health Clinical Practice Guideline Resource Guide.
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:

Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1).
9
Figure 1. GRADE Methodology adapted by UW Health
Rating Scheme for the Strength of the Evidence/Recommendations:

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
We are quite confident that the effect in the study is close to the true effect, but
Moderate
it is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice

Generally should be performed (i.e., the net benefit of the treatment is
Strong (S) clear, patient values and circumstances are unlikely to affect the
decision.)
May be reasonable to perform (i.e., may be conditional upon patient
Conditional (C) values and preferences, the resources available, or the setting in which
the intervention will be implemented.)
Recognition of Potential Health Care Disparities: use of the guideline is not expected to
result in health care disparities.
Collateral Tools & Resources

Not applicable
Metrics
1. Metrics include appropriate patient selection for “bridge” therapy, thromboembolic event up to 30
days after procedure, bleeding event up to 30 days after procedure, appropriate hold time of
antithrombotic in relation to procedure or neuraxial catheter placement or removal and
inappropriate administration of antithrombotic medications during neuraxial catheter placement.
2. Thromboembolic events in the absence of antithrombotic therapy in the periprocedural setting
3. Hemorrhagic events with antithrombotic therapy in the periprocedural setting
4. Hemorrhagic events with antithrombotic therapy with epidural or spinal catheter placement and
removal
10
Appendix A. Example 5-day hold bridging plan
Bridging Bridging
Medication Medication Labs/
Date Warfarin
Appointments
AM PM
Pre-Procedure
Hold Hold Hold
Day -5
Pre-Procedure
Hold Hold Hold
Day -4
Pre-Procedure
Bridging Dose Bridging Dose Hold
Day -3
Pre-Procedure
Bridging Dose Bridging Dose Hold
Day - 2
Pre-Procedure
Bridging Dose Hold Hold
Day -1
Procedure Day
mg
Hold Hold
( tablets)
Post Procedure
mg
Day 1 Bridging Dose Bridging Dose
( tablets)
Post Procedure
mg
( tablets)
Post Procedure
mg
( tablets)
Post Procedure
mg
( tablets)
Post Procedure
mg
Day 5 Bridging Dose Bridging Dose INR
( tablets)
KEY
Shaded cells: no doses administered
Unshaded cells: doses administered
11
Appendix B. Dosing of parenteral anticoagulants for periprocedural management
Drug Therapeutic Dose Prophylactic Dose

1 mg/kg SQ every 12 hours
Enoxaparin
(Round to nearest prefilled syringe size) 40 mg SQ every 24 hours
(Lovenox®)
Weight based
< 50 kg: 5 mg SQ every 24 hours
Fondaparinux
50-100 kg: 7.5 mg SQ every 24 hours 2.5 mg SQ every 24 hours
(Arixtra®)
>100 kg: 10 mg SQ every 24 hours
5000 units SQ every 12 hours

Refer to UWHC Guidelines for
UFH OR
therapeutic dosing of IV heparin
5000 units SQ every 8 hours
12
References
1. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of

antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Chest. 2012;141(2 Suppl):e326S-e350S.
2. Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral
anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Chest. 2012;141(2 Suppl):e44S-e88S.
3. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in
Patients with Atrial Fibrillation. N Engl J Med. 2015;373(9):823-833.
4. Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging
during anticoagulation interruptions in patients with atrial fibrillation: findings from the
Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF).
Circulation. 2015;131(5):488-494.
5. Committee ASoP, Anderson MA, Ben-Menachem T, et al. Management of
antithrombotic agents for endoscopic procedures. Gastrointest Endosc.
2009;70(6):1060-1070.
6. Witt DM, Delate T, McCool KH, et al. Incidence and predictors of bleeding or thrombosis
after polypectomy in patients receiving and not receiving anticoagulation therapy. J
Thromb Haemost. 2009;7(12):1982-1989.
7. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA, Jr., Caprini JA. A validation
study of a retrospective venous thromboembolism risk scoring method. Ann Surg.
2010;251(2):344-350.
8. Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term
interruption of warfarin therapy. Arch Intern Med. 2008;168(1):63-69.
9. Douketis JD. Perioperative anticoagulation management in patients who are receiving
oral anticoagulant therapy: a practical guide for clinicians. Thromb Res. 2002;108(1):3-
13.
10. Dabigatran (Pradaxa®) [prescribing information]. Boehringer Ingelheim Pharmaceuticals;
Ridgefield, CT. In:2012.
11. Rivaroxaban (Xarelto®) [prescribing information]. Janssen Pharmaceuticals, Inc.;
Gurabo, PR. In:2012.
12. Apixaban (Eliquis®) [prescribing information]. Brisol-Meyers Squibb, Inc.; Princeton, NJ.
In:2012.
13. Edoxaban (Savaysa®) [prescribing information]. Daiichi Sankyo, Inc.; Parsippany, NJ.
In:2015.
14. Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative Management of Patients
With Atrial Fibrillation Receiving a Direct Oral Anticoagulant. JAMA Intern Med. 2019.
15. O'Donnell MJ, Kearon C, Johnson J, et al. Brief communication: Preoperative
anticoagulant activity after bridging low-molecular-weight heparin for temporary
interruption of warfarin. Ann Intern Med. 2007;146(3):184-187.
16. Hirsh J, Bauer KA, Donati MB, Gould M, Samama MM, Weitz JI. Parenteral
anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition). Chest. 2008;133(6 Suppl):141S-159S.
17. Fondaparinux (Arixtra®) [prescribing information]. Organon Sanofi-Synthelabo; West
Orange, CT. In:2002.
18. Bivalirudin (Angiomax®) [prescribing information]. The Medicines Company; Parsippany,
NJ. In:2005.
13
19. Argatoban [prescribing information]. GlaxoSmithKline; Research Triangle Park, NC.

In:2014.
20. Eikelboom JW, Hirsh J, Spencer FA, Baglin TP, Weitz JI. Antiplatelet drugs:
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2
Suppl):e89S-e119S.
21. Writing Committee M, Jneid H, Anderson JL, et al. 2012 ACCF/AHA focused update of
the guideline for the management of patients with unstable angina/Non-ST-elevation
myocardial infarction (updating the 2007 guideline and replacing the 2011 focused
update): a report of the American College of Cardiology Foundation/American Heart
Association Task Force on practice guidelines. Circulation. 2012;126(7):875-910.
22. Hall R, Mazer CD. Antiplatelet drugs: a review of their pharmacology and management
in the perioperative period. Anesth Analg. 2011;112(2):292-318.
14

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Effective 10-17-2019. Contact CCKM@uwhealth.org for previous versions.

Periprocedural Management with Antithrombotic

Contact for Changes:

Clinical Questions Considered:

1. Periprocedural or Bridging Anticoagulation – administration of a short acting anticoagulant

3. Antithrombotic therapy – includes any anticoagulant or antiplatelet medication

Periprocedural Antithrombotic Management

Venous • VTE within previous 3 months

Sphincterotomy Hold anticoagulation*

> 4.5 Stop 6-7 days before procedure

3. Direct Oral Anticoagulants (DOACs)1,2,10,11,12,13 – Listed Alphabetically

Bivalirudin CrCl ≥ 30 mL/min Stop 1.5 hours before procedure

Enoxaparin Prophylactic Dosing Stop 12 hours before procedure

Fondaparinux CrCl ≥ 50 mL/min Stop 3 days before procedure

5. Antiplatelet Therapy1,20,21,22 – Listed Alphabetically

Methods Used to Collect the Evidence:

Time Period: 2000 to 2019

Methods to Select the Evidence:

Methods Used to Formulate the Recommendations:

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:

Figure 1. GRADE Methodology adapted by UW Health

Rating Scheme for the Strength of the Evidence/Recommendations:

GRADE Ratings for Recommendations For or Against Practice

Collateral Tools & Resources

Appendix A. Example 5-day hold bridging plan

Unshaded cells: doses administered

Appendix B. Dosing of parenteral anticoagulants for periprocedural management

Drug Therapeutic Dose Prophylactic Dose

5000 units SQ every 12 hours

1. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of

19. Argatoban [prescribing information]. GlaxoSmithKline; Research Triangle Park, NC.

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