Management of Novel Oral Anticoagulants in the Perioperative Setting

For decades warfarin has been the oral anticoagulant of choice. However, in recent years there has been a significant shift towards the use of NOACs. Unlike most other medications, such as warfarin [1] and anti-hyperglycaemic agents [2], the protocol for perioperative cessation of NOACs remains unclear. The aim of this review is to summarise a growing body of evidence surrounding the perioperative management of NOACs; dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis). NOACs hold many advantages over warfarin in the management of procoagulant disorders, such as their rapid onset with no bridging required, short half-life allowing timely cessation and not requiring monitoring blood tests [3-5]. The advantage of not requiring monitoring blood tests is, however, a disadvantage in the perioperative setting, as coagulation studies are therefore a poor predictor of agent reversal [6]. What’s more, reversal is difficult. The cessation of these agents is currently based on their relatively predictable pharmacokinetics, which is strongly related to renal function [7,8].