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The vexed question of whether or not to measure levels of direct oral anticoagulants before surgery or invasive procedures

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Abstract

Direct oral anticoagulants (DOAC) possess high bioavailability, and their anticoagulant effect is more predictable than that of vitamin K antagonists, hence they do not require routine dose adjustment based on laboratory testing. However, there are circumstances when laboratory testing may be useful, including patients who need to undergo surgery or invasive procedures. Most guidelines state that patients on DOAC may safely undergo surgery/invasive procedures by stopping anticoagulation for a few days before intervention without testing if renal function is within normal limits. This review article discusses the pros and cons of measuring (or not measuring) DOAC levels before surgery/invasive procedures by a multidisciplinary team of experts with different background, including the thrombosis laboratory, clinical thrombosis, internal medicine, cardiology and nephrology. The conclusion is that measuring DOAC with dedicated tests before surgical or invasive procedures is important for patient safety. It provides the best and most direct evidence to rule in (or to rule out) clinically relevant concentrations of residual drugs. Regulatory agencies should urgently approve their use in clinical practice. Hospital administrators should make them available, and clinical laboratories should set up the relative methods and make them available to clinicians.

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Author information

Authors and Affiliations

  1. Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, Via Pace 9, 20122, Milan, Italy

    Armando Tripodi & Marco Moia

  2. Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy

    Francesco Marongiu

  3. Arianna Anticoagulation Foundation-START Register Section, Bologna, Italy

    Gualtiero Palareti

  4. Cardiology Clinic, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy

    Vittorio Pengo

  5. Thrombosis Centre, Careggi University Hospital, Florence, Italy

    Daniela Poli

  6. Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy

    Domenico Prisco

  7. Department of Laboratory Medicine, Hemostasis and Thrombosis Centre, District Hospital, Cremona, Italy

    Sophie Testa

  8. Renal Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy

    Maria Zanazzi

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  1. Armando Tripodi
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  2. Francesco Marongiu
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  3. Marco Moia
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  4. Gualtiero Palareti
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  5. Vittorio Pengo
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  6. Daniela Poli
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  7. Domenico Prisco
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  8. Sophie Testa
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  9. Maria Zanazzi
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Correspondence to Armando Tripodi.

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Tripodi, A., Marongiu, F., Moia, M. et al. The vexed question of whether or not to measure levels of direct oral anticoagulants before surgery or invasive procedures. Intern Emerg Med 13, 1029–1036 (2018). https://doi.org/10.1007/s11739-018-1854-6

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