Table 7. Management of patients on Direct Oral Anticoagulants (DOACs) in the perioperative period undergoing procedures with a high bleeding risk
See here for prescribing information on prophylactic and therapeutic doses of Low Molecular Weight Heparin (LMWH).
| Prior to procedure | |
| Low risk of thrombosis | High risk of thrombosis |
|
Stop DOAC prior to procedure in line with times in table 6. There is no need to give any LMWH pre-operatively in the elective setting. In the unplanned / acute setting, the DOAC may be withheld pending a procedure. In this case, prophylactic dose LMWH would be appropriate while the DOAC is withheld. LMWH should be started at 6pm, at least 24 hours after the last dose of DOAC. |
Stop DOAC prior to procedure in line with times in table 6. There is no need to give any LMWH pre-operatively in the elective setting. In the unplanned / emergency setting, the DOAC may be withheld pending a procedure. In this case, the surgical team should consider whether to treat with therapeutic dose LMWH while the DOAC is withheld. LMWH should be started at 8am, at least 24 hours after the last dose of DOAC. It should be discontinued at least 24 hours prior to the procedure. |
| Day of procedure | |
| Low risk of thrombosis | High risk of thrombosis |
| No monitoring is required prior to the procedure unless the timescales in table 6 have not been met.1 | |
| Post procedure | |
| Low risk of thrombosis | High risk of thrombosis |
|
If adequate haemostasis, consider prophylactic dose LMWH at 6pm (or 4 hours post-op, whichever is later). This should continue the day following the procedure also. The DOAC can be considered for restarting 2 days following the procedure. If the team do not want to start the DOAC at this stage, prophylactic dose LMWH should continue until the patient is deemed suitable to restart the DOAC. |
If adequate haemostasis, consider prophylactic dose LMWH at 6pm (or 4 hours post-op, whichever is later). This should continue the day following the procedure also. The DOAC can be considered for restarting 2 days following the procedure. If the team do not want to start the DOAC at this stage, prophylactic dose LMWH should be continued, or therapeutic dose LMWH can be considered, until the patient is deemed suitable to restart the DOAC.2 |
| Restarting the DOAC | |
| Low risk of thrombosis | High risk of thrombosis |
|
The DOAC can be restarted after a minimum of 12 hours after the last dose of prophylactic LMWH and be based on the patient's usual dosing time. At least 6 hours must have elapsed from removal of an epidural catheter before restarting the DOAC. |
The DOAC can be restarted no earlier than 12 hours after the last dose of prophylactic LMWH, with consideration given to the patient's usual dosing time. At least 6 hours must have elapsed from removal of an epidural catheter before restarting the DOAC. If on treatment dose LMWH, the DOAC should be started no earlier than when the next dose of LMWH is due. |
| ***DOAC and LMWH should not be prescribed concurrently*** | |
1. If monitoring is required for apixaban, edoxaban or rivaroxaban, a desired level of <25ng/ml measured by specific anti-Xa assay is required to proceed. A level above this should be discussed with haematology. For dabigatran, pre-operative assessment of routine coagulation screen may not accurately reflect the level of anticoagulation, although a normal Thrombin Clotting Time (TCT) would imply negligible dabigatran levels. If the time scales in table 6 have not been met, discuss with haematology.
2. There might be instances where the surgical team prefer to use LMWH post-operatively at treatment doses rather than restarting the DOAC. This would be advantageous due to the shorter half-life of LMWH, allowing a shorter time period between the last dose and an unexpected surgical intervention being required. Examples where this may be desirable include: increased bleeding risk; potential need to return to theatre; oral route unavailable; and acute kidney injury.
Guideline reviewed: August 2025
Page updated: July 2026
