Anticoagulants Platelet Inhibitors and Direct Thrombin Inhibitors.xlsx

Medication (Brand Name)
(Classification)
Apixaban (Eliquis)
(Factor Xa Inhibitor)
Aspirin
(Antiplatelet)
Cilostazol (Pletal)
(Platelet Aggregation Inhibitor)
Clopidogrel (Plavix)
(Platelet Aggregation Inhibitor)
Dabigatran (Pradaxa)
(Direct Thrombin Inhibitor)
Dipyridamole/Aspirin (Aggrenox)
(Platelet Aggregation
Inhibitor/Antiplatelet)
Dipyridamole (Persantine)
(Platelet Aggregation Inhibitor)
Enoxaparin (Lovenox)
(Low Molecular Weight Heparin)
Fondaparinux (Arixtra)
(Factor Xa Inhibitor)
Anticoagulants, Platelet Inhibitors, and Direct Thrombin Inhibitors
Perioperative Considerations Special Considerations Reversal Lab Monitoring
CrCl > 60 ml/min: Stop 1‐2 Days
CrCl 50‐59 ml/min: Stop 3 Days
CrCl < 30‐49 ml/min: Stop 5 Days
May restart after hemostasis achieved
Wait 48 hours after high risk procedures before resuming
Black box warning for abrupt discontinuation
Contraindicated in active major bleeding
Precaution for bleeding risk, use in pregnancy, use in
significant renal or hepatic impairment
Avoid use in hip fracture surgery
NONE**
PCC (Bebulin) (theoretical)
rFVIIa (Novo‐Seven) (theoretical)
Anti‐factor Xa*
PT/INR
aPTT
CBC with differential
LFT's
SCr
Stop for 7‐10 days
May restart within 24 hours
DO NOT STOP IF HX. of CORONARY STENT
Contraindicated in bleeding disorders
Contraindicated in significant hepatic or renal impairment
Contraindicated within 24 hours after alteplase (tPa) use
Platelets
Desmopressin (DDAVP)
Platelet Function
Assay
Aspirin Level
Hg/Hct
Stop for 2 days
May restart after hemostasis achieved
Stop for 5 days***
Restart as soon as possible after procedure
Reinitiate within 24 hours after the procedure
CrCl >/=50 mL/min: Stop for 1‐2 Days
CrCl < 50 mL/min: Stop for 3‐5 Days
For High risk procedures wait 48 hours
Restart after hemostasis achieved
Black box warning for use in heart failure
Contraindicated in active bleeding
Contraindicated in bleeding disorders
Black box warning for use in poor metabolizers
Contraindicated during active bleeding
Precaution for use in surgery
Precaution for stopping use in patients with recent
coronary stent insertion (Minimum of 6 weeks of
therapy post BMS & Minimum of 6 months of therapy
post DES).
Contraindicated in active bleeding
Precaution for bleeding risk
Precaution for temporary discontinuation
Methylprednisolone (Solu‐Medrol) 20 mg IV
Platelets
Platelets
Desmopressin (DDAVP)
NONE**
FFP (partial)
Dialysis (removes 60% in 2 hours)
PCC (Bebulin) (theoretical)
rFVIIa (Novo‐Seven) (theoretical)
Hg/Hct
P2Y12
Hg/Hct
aPTT
TT
ECT*
CBC with differential
SCr
Stop for 7‐10 days
Restart as soon as possible after procedure
Precaution for bleeding risk
Precaution for use in severe renal or hepatic impairment
Precaution for use in pregnancy
Platelets
Desmopressin (DDAVP)
Hg/Hct
Stop for 2 days
Restart as soon as possible after procedure
Precaution for use in hepatic impairment
Platelets
Desmopressin (DDAVP)
NONE
Stop for 24 hours
May restart within 24 hours (for low bleeding risk)
May restart within 48 to 72 hours (for high bleeding risk)
Black box warning for spinal/epidural anesthesia
Contraindicated in active major bleeding
Protamine (partial)
anti‐factor Xa*
Hg/Hct
Platelets
SCr
Stop for 36‐48 hours
May restart within 24 hours (for low bleeding risk)
May restart within 48 to 72 hours (for high bleeding risk)
Black box warning for spinal/epidural anesthesia
Contraindicated in active major bleeding
Contraindicated in severe renal impairment
Contraindicated in thrombocytopenia
NONE**
FFP
Cryoprecipitate
rFVIIa (Novo‐Seven)
anti‐factor Xa*
CBC
SCr
Fecal Occult Blood
Revised: July 2013

Anticoagulants, Platelet Inhibitors, and Direct Thrombin Inhibitors
Medication (Brand Name)
(Classification)
Heparin
(Anticoagulant)
Herbal Supplements
Perioperative Considerations Special Considerations Reversal Lab Monitoring
IV: Stop for 2‐6 hours depending on the dose
Subq: Stop for 12‐24 hours depending on the dose
May restart within 24 hours (for low bleeding risk)
May restart within 48 to 72 hours (for high bleeding risk)
Stop for 7 days
Black box warning for use of benzyl alcohol preserved
product in neonates
Contraindicated in severe thrombocytopenia
Contraindicated in uncontrolled, active bleeding (except
DIC)
Contraindicated in patients with history of HIT
Protamine
aPTT
anti‐factor Xa*
ACT
Hg/Hct
Platelets
Fecal Occult Blood
Various supplements increase the risk for bleeding N/A N/A
NSAID's Stop for 1‐3 days
All NSAID's (other than aspirin) may cause reversible
inhibition of platelet function and should be stopped
perioperatively to reduce the risk of bleeding associated
with reduced platelet function
N/A N/A
Prasugrel (Effient)
(Platelet Aggregation Inhibitor)
Stop for 7 days***
Restart as soon as possible after procedure
Black box warning for bleeding risk
Black box warning for use in active bleeding
Black box warning for use in patients 75 and older or
weighing less than 60 kg
Contraindicated if history of TIA or stroke
Precaution for stopping use in patients with recent
coronary stent insertion (Minimum of 6 weeks of
therapy post BMS & Minimum of 6 months of therapy
post DES).
Platelets
Desmopressin (DDAVP)
P2Y12
Hg/Hct
Rivaroxiban (Xarelto)
(Factor Xa Inhibitor)
Stop for 1 Day when renal function is WNL
Stop for 2 Days with CrCL 60‐90 mL/min
Stop for 3 Days with Cr. CL of 30‐59 mL/min
Stop for 4 Days with Cr.CL 15‐29 mL/min
May restart within 6 hours
For High risk procedures: wait 48 hours before resuming
Black box warning for spinal/epidural anesthesia
Contraindicated in active major bleeding
Precaution for bleeding risk, use in pregnancy, use in
significant renal or hepatic impairment
NONE**
PCC (Bebulin) (theoretical)
rFVIIa (Novo‐Seven) (theoretical)
Anti‐factor Xa*
PT/INR
aPTT
CBC with differential
LFT's
SCr
Ticagrelor (Brilinta)
(Platelet Aggregation Inhibitor)
Stop for 5 days***
Restart as soon as possible after procedure
Black box warning for bleeding risk
Black box warning for stopping use
Precaution for use with aspirin doses above 100 mg
Platelets
Desmopressin (DDAVP)
P2Y12
Hg/Hct
SCr
Uric Acid level
Ticlopidine (Ticlid)
(Platelet Aggregation Inhibitor)
Stop for 10‐14 days***
Restart as soon as possible after procedure
Black box warning for blood dyscrasias (TTP, neutropenia,
or aplastic anemia)
Precaution for bleeding risk
Precaution use in sig renal/hepatic impairment
Platelets
Desmopressin (DDAVP)
P2Y12
CBC with differential
LFT's
Warfarin (Coumadin)
(Coumadin Anticoagulant)
Stop for 1‐8 days depending on the INR
INR decreases to

Anticoagulants, Platelet Inhibitors, and Direct Thrombin Inhibitors
Approach to Bridging Therapy
Condition: Bridging Therapy Required: No Bridging Therapy: Comments:
Mechanical Heart Valve Mitral‐value replacement, two or more mechanical
valuves, nonbileaflet aortic‐valves, replacement, or
aortic‐value replacement with other risk factors.
Aortic‐valve replacement, bileaflet
prosthesis, and no additional risk factors.
Other risk factors include prior
stroke, TIA, intracardiac thrombus,
or cardioembolic event.
Nonvalvular Atrial Fibrillation Prior stroke or embolic event, cardiac thrombus, No prior stroke or embolic event, Prior stroke, TIA, intracardiac
or CHADS score >/= 4. absence of thrombus, or CHADS score thrombus, or cardioembolic
of < 4. event increases risk.
Venous Thromboembolism Venous thromboembolism within previous 3 Venous thromboembolism > 3 months Consider inferior vena cava
months or severe thrombophilia. previously or no additional risk factors filter if venous thromboembolism
(e.g. active cancer and nonsevere
thrombophilia). occurred < 1 month previously, if
urgent or emergent surgery is
required, or if there is a
contraindication to anticoagulation
therapy.
Medications High risk patients with CrCL < 30 mL/min: Use Heparin
Mechanical Heart Valve or Afib: Lovenox 1 mg/kg
every 12 hours.
Hx VTE: Lovenox 1.5 mg/kg daily
Source: The New England Journal of Medicine 368;22. May 30, 2013
Revised: July 2013