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Management plan for patients on warfarin and direct oral anticoagulants (DOACs) in the peri-operative period

This is an abbreviated version of the full GGC guideline Management plan for patients on warfarin and direct oral anticoagulants (DOACs) in the peri-operative period.  

Scope of this guideline

For the purposes of this guideline, the following clinical situations are not covered: 

  • Neurosurgery 
  • Vascular surgery 
  • Orthopaedic trauma
  • Pregnancy and 6 weeks post-partum
  • Interventional radiology patients 
  • Paediatrics 

Introduction

This guideline aims to balance the competing risks of thrombosis versus haemorrhage, which occur in the peri-operative period, for patients anticoagulated with warfarin or direct oral anticoagulants (DOACs).

In doubtful cases it is usually safer to omit anticoagulant drugs rather than over treat, but each case needs individual assessment. Consult senior colleagues and/or seek Haematology advice promptly in unclear cases.

Haemorrhage and Emergency Invasive Procedures

Most anticoagulated patients admitted with trauma, major bleeding or for emergency surgery, have risks from haemorrhage that usually far outweigh the thrombotic risks (even in high thrombotic risk patients). Full and immediate anticoagulation reversal is required:

  1. Check full coagulation screen, full blood count, INR (if on warfarin) and cross-match blood.
  2. Withhold warfarin or DOAC.
  3. Reverse anticoagulation fully and rapidly (see Reversal of Antithrombotic Therapies guideline).
  4. If any concerns or uncertainty, discuss with on-call Haematologist.
  5. Proceed to surgery as appropriate.
  6. Only when you are sure the risk of bleeding has abated, re-anticoagulate as appropriate using the patient's thrombotic risk category (as per the recommendations below).

Elective Procedures

Risk Stratification

Invasive procedures can be classified according to their bleeding risk and patients can be classified according to the thrombosis risk of their underlying conditions. These two factors need to be considered to determine the most appropriate management throughout the peri-operative period. Tables 1-3 below should be used to categorise the bleeding and thrombosis risk for individual patients. 

NB: Some patients or procedures may not be easily classified into the following categories - if so, they should be discussed with the relevant senior clinician (e.g. haematologist, cardiologist, surgeon). 

Table 1 – List of procedures categorised by bleeding risk

Low risk of bleeding:

  • Standard dental procedures e.g. simple extractions <4 teeth
  • Routine upper gastrointestinal (GI) endoscopy or colonoscopy including simple biopsy (unless part of the national bowel cancer screening programme - see below)
  • Cataract extraction and lens implantation
  • Bone marrow biopsy
  • Joint injections (refer to separate guideline available here). 

High risk of bleeding:

  • Any colonoscopy performed as part of the national bowel cancer screening programme, polypectomy, endoscopic treatment of varices, or ERCP
  • Most formal surgical procedures
  • Anaesthesia involving spinal or epidural anaesthetic

Extremely high risk of bleeding:

  • Neurosurgical interventions

Table 2 – List of conditions categorised by thrombosis risk

Low risk of thrombosis:

  • Atrial fibrillation with CHA2DS2-VA score <5 (with the exceptions below)
  • Venous thromboembolism >3 months previously (including patients with recurrent VTE) 

High risk of thrombosis:

  • Atrial fibrillation
    • within 3 months of a stroke, TIA or embolism
    • with CHA2DS2-VA score ≥5 (see table 3 below)
    • with moderate or severe mitral stenosis irrespective of CHA2DS2-VA score
  • Venous thrombosis
    • within previous 3 months
    • with known high-risk thrombophilia (e.g. deficiencies of Protein C, S, antithrombin; antiphospholipid syndrome) 
  • Prior recurrent venous thrombosis with target INR 3.5

Extremely high risk of thrombosis: 

  • Mechanical heart valve in any position. 

Table 3 - CHA2DS2-VA Score 

Condition Points
Congestive Heart Failure  1
Hypertension 1
Age ≥75 2
Age 65-74 1
Diabetes Mellitus 1
Stroke / TIA / Thromboembolism history  2
Vascular Disease (prior MI, peripheral artery disease, aortic plaque) 1
Adapted from the 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): Developed by the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC), with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. European Heart Journal. 2024:45(36);3314-3414.

Management

Based on the anticoagulant the patient is on, and the thrombosis / bleeding risk (determined by tables 1-3 above), follow the relevant section for management:

Elective procedures with a high risk of bleeding

NB: For elective procedures with an extremely high risk of bleeding (e.g. neurosurgery), consult the appropriate senior colleague (do not apply the recommendations below).

Warfarin

DOACs

 

For prescribing information on prophylactic and therapeutic doses of Low Molecular Weight Heparin (LMWH) referred to in these tables, see here.  

Elective procedures with a low risk of bleeding

Warfarin

In general, standard dental procedures, routine endoscopy +/- simple biopsy and cataract surgery can be undertaken without interrupting warfarin therapy.  These patients should have their INR checked within 48 hours prior to surgery or intervention to ensure levels are not supra-therapeutic and are ideally <3.5. For joint injections see GGC guideline for information. 

DOACs

      • Minor dental work 

  • Dental procedures with low or no bleeding risk can usually be undertaken without interrupting DOAC therapy.
  • For procedures with a higher risk of bleeding, omit the morning DOAC dose.
  • Undertake the dental procedure early in the day. Limit the initial treatment area and assess bleeding before continuing. 
  • Actively consider suturing or packing. 

Post-procedure: 

  • For patients taking dabigatran, edoxaban or rivaroxaban once daily in the evening, the evening dose should be taken at the usual time, but at least 4 hours after dental haemostasis has been achieved. 
  • For patients taking apixaban or rivaroxaban twice daily, the deferred morning dose can either be omitted entirely or taken at least 4 hours after dental haemostasis has been achieved, providing the dose would not be taken within 6 hours of the next scheduled dose.
  • For patients taking dabigatran twice daily, the deferred morning dose should be omitted and the evening dose should be taken at the usual time, but at least 4 hours after dental haemostasis has been achieved.  

      • Joint injections 

See GGC guideline Oral Anticoagulants and Joint / Soft Tissue Injections.

      • Cataract surgery and endoscopy (excluding polypectomy or sphincterotomy) 

  • In the majority of patients omit the DOAC dose on the morning of the procedure. 
  • Depending on renal function, longer periods of omission may be needed - see Table 8. 
  • Do not recommence DOAC until 4-6 hours post procedure (or longer if haemostasis has not been achieved). 

Table 8: Timeframe between last dose of DOAC and minor invasive procedure with low bleeding risk.

CrCl (ml/min) Apixaban, Edoxaban & Rivaroxaban Dabigatran
>30ml/min 

Take the last dose the day before the procedure (no later than 8pm) 

Take the last dose in the morning the day before the procedure 
≤30ml/min 

Take the last dose 2 days before the procedure. E.g. for an endoscopy on Wednesday, the last dose should be taken on Monday 

Contraindicated

Special Considerations 

For advice on how to manage DOACs and/or warfarin in neuro-axial anaesthesia (including spinal and epidural catheters) and lumbar puncture please see section 4 of the full guideline here. 

Bridging therapy with unfractionated heparin (UFH), for high thrombotic risk patients, in the peri-operative period

Use of unfractionated heparin (UFH) may occasionally be preferable to using LMWH e.g. when the ability to ensure rapid and complete reversal of heparin is required, where significant renal impairment exists or where standard monitoring of heparin effect is necessary. If an UFH infusion is required, and the patient is already on therapeutic dose LMWH, the LMWH should be stopped and the UFH infusion started when the next dose of LMWH was scheduled. 

  1. Commence UFH according to the schedule detailed in the Drug Therapy section of the Diagnosis and Treatment of Venous Thromboembolism guideline.
  2. Monitor APTT ratio and adjust UFH dose in line with the guideline above to achieve a result of 1.8-2.8.
  3. Stop UFH 6 hours pre-operatively.
  4. Recommence UFH 8 hours post-op (assuming haemostatic) at 50% of prior therapeutic dose. N.B. Do not give a loading dose post-operatively.
  5. Assess APTT ratio on day +1 and slowly adjust UFH dose to achieve an APTT ratio of 1.5-2.0
  6. Stop UFH for 6 hours prior to removal of any epidural catheters
  7. Only after any epidural has been removed, restart usual anticoagulation as soon as it is safe and GI tract function is judged adequate. This must be at least 6 hours after removal of any epidural catheters - see full guideline for more detail and timeframes.  
  8. On day +2 monitor APTT ratio and, only after any epidural has been removed, slowly adjust UFH to achieve a ratio of 1.8-2.8.
  9. Continue UFH until INR is ≥2.

If good haemostasis has been secured and maintained for 2-3 days post-procedure it may be reasonable to switch from IV UFH to therapeutic dose LMWH. LMWH dosing should be chosen based on thrombotic risk (table 2 and table 5) and should commence 4 hours after cessation of the UFH infusion. If exposure to UFH (and LMWH) exceeds 4 days, monitor platelet count every 2-3 days from day 4 to 14, or until heparin is stopped. Be alert for evidence of heparin induced thrombocytopenia (HIT).

 

Guideline reviewed: August 2025

Page updated: July 2026