Each week we will aim to bring out a concise email that provides 4-5 key pieces of information addressing a specific issue in clinical therapeutics.
This week: Direct/Newer Anticoagulants Part 2
Saly Rashed, Clinical Pharmacist, Ward MM
- Decision to continue anticoagulants during surgery or not, and when to stop and restart involves balancing the risks of thromboembolism against the risk of bleeding.
- In patients with normal renal function who are undergoing a low bleeding risk surgery, it is usually recommended to have the last dose of DOACs 24 hours prior to surgery. In patients with normal renal function and undergoing high bleeding risk surgery, it is usually recommended to have the last dose of DOACs 48-72 hours prior to surgery.
- Treatment may be re-commenced 24 hours post low bleeding risk surgery and 48-72 hours post high bleeding risk surgery.
- It is important to note that DOACs do not need monitoring but the people taking them do!
- A limiting factor in the use of the newer oral anticoagulants is that, unlike warfarin, there have been no antidotes. Reversal of anticoagulation may be required if the patient develops severe bleeding or requires emergency surgery. Idarucizumab has been developed to reverse the effect of dabigatran, a direct thrombin inhibitor.
- The development of idarucizumab involved genetically engineering a humanised monoclonal antibody fragment. The affinity of this antibody for dabigatran is greater than the affinity of dabigatran for thrombin.
- Although idarucizumab effectively reverses the anticoagulant effect of dabigatran, patients still require other supportive treatments. As the drug is specific for dabigatran it should not be used to reverse the effects of other anticoagulants.
Please consider these issues when preparing or interpreting RMMR reports or education sessions. Contributions of content or suggested topics are welcome and should be sent directly to email@example.com.