Interruption and Reversal of Direct Oral Anticoagulants in Preprocedural and Acute Settings

Article Figures & Data

Table 1.

Anticoagulation for Atrial Fibrillation in Specific Clinical Scenarios¹⁴

Category	Recommendations
Stable CAD and PAOD	-DOAC mostly without use of antiplatelet agents
After coronary stenting	-Triple therapy with VKA (target INR, 2 to 2.5) or reduceddose DOAC^*, aspirin 75 to 100 mg/d, and clopidogrel 75 mg /d
After coronary stenting	-Consider: bare metal stents, abbreviated 6-month dual antiplatelet therapy for drug eluting stent or omission of aspirin if bleeding propensity is high
Secondary stroke prevention	-DOACs preferred over VKA unless TTR >70
Secondary stroke prevention	-No addition of antiplatelet agent to OAC is needed.
Acute stroke	-r-tPA only if anticoagulation by test or history is minimal
Acute stroke	-Mechanical thrombectomy for proximal intracranial occlusion
Acute ischemic stroke after neuroimaging (repeat imaging pre-OAC for moderate to severe ischemic stroke)	- TIA start OAC immediately
	- Mild ischemic stroke, start OAC after 3 days
	- Moderate ischemic stroke, start OAC at 5 to 7 days
	- Severe ischemic stroke, start OAC at 12 to 14 days
History of GI bleed	-Preference to apixaban and low dose dabigatran
Hemodialysis	- VKA or no OAC (DOACs not approved if CrCl <15 mL/m)
Cardioversion	-VKA and DOACS appear to be similarly effective
AF- Ablation	-Preferred VKA over DOACS (limited data on edoxaban)
Mechanical valves	-VKA target INR based on valve type, site and associated conditions along with aspirin 75 to 100 mg daily
Mod/severe rheumatic mitral stenosis	VKA target INR 2 to 3

CAD, coronary artery disease; DAOC, direct oral anticoagulants; GI, gastrointestinal; AF, atrial fibrillation; TTR, Time in Therapeutic Range; OAC, oral anticoagulants; TIA; transient ischemic attack; r-tPA, recombinant tissue plasminogen activator; PAOD, peripheral arterial occlusive disease; VKA, vitamin K antagonists.
↵* Apixaban 2.5 mg BID.

Table 2A.

Recommended Durations for Interrupting Oral Direct Thrombin Inhibitor in the Preprocedural Setting: Dabigatran^43,57,73

Creatinine Clearance (ml/min)	Estimated Half-Life (hours)	Duration of Interruption
Creatinine Clearance (ml/min)	Estimated Half-Life (hours)	Low PBR	Intermediate/High/Uncertain PBR
≥80	13	≥24 hours	≥48 hours
50 to 79	15	≥36 hours	≥72 hours
30 to 49	18	≥48 hours	>96
15 to 29	27	≥72 hours	≥120 hours
<15	30 (off dialysis)	No data^* Consider ≥96 hours	No data

Table 2B.

Recommended Durations for Interrupting Oral Factor Xa Inhibitor in the Preprocedural Setting: Apixaban, Edoxaban, and Rivaroxaban^57,74–76

Creatinine Clearance (ml/min)	Estimated Half-Life (hours)	Duration of Interruption
Creatinine Clearance (ml/min)	Estimated Half-Life (hours)	Low PBR	Intermediate/High/Uncertain PBR
≥30	6 to 15	≥24 hours	≥48 hours
15 to 29	Apixaban: 17	≥36 hours	No data
	Edoxaban: 17		Consider ≥72 hours^*
	Rivaroxaban: 9
<15	Apixaban: 17^{^†}	No data	No data
	Edoxaban: 10 to 17^{^†}	Consider ≥48 hours^*	Consider ≥72 hours^*
	Rivaroxaban: 13^{^†}

Table 3.

Direct Oral Anticoagulant Characteristics: Interruption and Reversal⁵⁴

Characteristics	Dabigatran	Rivaroxaban	Apixaban	Edoxaban
Mechanism	IIa inhibitor	Xa inhibitor	Xa inhibitor	Xa inhibitor
Specific reversal agents (first line)	Praxbind (idarucizumab)	Andexanet	Andexanet	Andexanet
		Alfa^*	Alfa^*	Alfa^*
		Ciraparantag^*	Ciraparantag^*	Ciraparantag^*
Second line reversal agents	aPCC	aPCC	aPCC	aPCC
Second line reversal agents	4F- PCC