Asked and Answered: Anticoagulation and Surgery

Earlier this summer, NATF hosted an interactive Ask the Expert panel on anticoagulation. Andrea Lewin, Beata Rucinski, and Themio Papadopoulos, all pharmacists specializing in anticoagulation management, joined us to answer patients’ most pressing questions about blood thinners. Part of the forum specifically focused on blood thinners and surgical procedures. Missed the event? Here are some of the key questions that were addressed.

Q: I’m on a blood thinner and need to have an operation. Who will manage my anticoagulation in the setting of surgery?

“First and foremost, if you’re on a blood thinner, it’s critically important to inform the proceduralist or surgeon as well as the rest of your healthcare team, which would include your primary care provider, cardiologist, and/or any other clinician who prescribes your blood thinner. If you work with an anticoagulation pharmacist, they should also be aware that you’re having surgery,” says Dr. Papadopoulos.

However, exact anticoagulation protocols may vary from institution to institution. For example, not all hospitals have an anticoagulant management service in place or anticoagulant pharmacists on staff. “Ultimately, the anticoagulation piece is in the hands of the surgeon and the broader team that manages the surgical patients – but hospitals do have specific anticoagulation guidelines to use in surgical patients,” Dr. Rucinski explains.

Q: Do I need to stop taking my blood thinner if I’m having surgery?

There are a few key factors to consider when an anticoagulated patient needs surgery:

1. The risk of bleeding associated with the procedure
2. The type of anticoagulant the patient takes – warfarin versus a direct oral anticoagulant (DOAC), such as rivaroxaban (Xarelto^®), apixaban (Eliquis^®), edoxaban (Savaysa^®), and dabigatran (Pradaxa^®)
3. The patient’s risk for a blood clot if anticoagulation is interrupted before surgery

If the procedure carries a high bleeding risk, your healthcare team may decide to temporarily stop your blood thinner before the procedure. Compared to DOACs, warfarin has a longer half-life, meaning that the medication takes more time to leave your body. Typically, warfarin is stopped 3-5 days before a surgery. However, if your risk for a blood clot is considered high while off warfarin, your provider may choose to “bridge” you with an injection. Bridging refers to the use of short-acting anticoagulants like heparin or low-molecular-weight-heparin (LMWH) before a procedure if you’ve stopped your usual blood thinner.

DOACs have a short half-life – they leave your body more quickly than warfarin. Depending on things like your kidney function and age, DOACs are usually stopped 1-3 days before a procedure. There’s typically no need to bridge patients taking DOACs since the medications wear off so quickly. After the procedure—when your doctor says you can resume anticoagulation—DOACs begin working within 4-8 hours to protect you from blood clots.

While DOACs may be more convenient, there are patients who may be unable to use a DOAC, or the DOAC may not be affordable. Regardless of what blood thinner you take, your anticoagulation/ surgical team will work with you to make a plan that’s specifically tailored to your needs and that seeks to balance your risk for bleeding with your risk for blood clots.

Q: I have a genetic clotting disorder and have had a pulmonary embolism (PE). Now I need a knee replacement. What should I do about my blood thinner?

According to Dr. Lewin, this is a fairly common situation. Providers do encounter patients with a history of blood clots and genetic clotting issues who need an operation. The blood clot history is the first consideration. Was the clot recent or did it happen 20 years ago? Have you had another blood clot since? Timing certainly plays a role in how you’d be managed in an operative setting.

The other thing to consider is the genetic clotting disorder itself, which is called thrombophilia. While the exact protocol may vary from patient to patient, your healthcare team may want to bridge your anticoagulation for a couple of days leading up to the procedure if your blood clot was recent (within the last 3-6 months) and you have thrombophilia.

Q: I have not personally had a blood clot but have close relatives who have had clots. Is that something I should mention to my provider if I need surgery?

“That would be important to mention to your doctor, regardless of whether you need surgery. A family history of blood clots may not be something that’s routinely checked if you haven’t had a blood clot yourself,” says Dr. Papadopoulos. Current guidelines don’t recommend routine genetic testing for thrombophilia because even if you may have a predisposition to clotting, anticoagulation typically wouldn’t be warranted unless you’ve had a blood clot yourself. However, your provider should still be informed if someone in your family has had a clot.

A big thank you to our expert pharmacists for weighing in on these questions!

Andrea Lewin, PharmD is an Advanced Practice Clinical Specialist at Brigham and Women’s Hospital Anticoagulation Management Service. She is a nationally board-certified Anticoagulation Care Provider.

Beata Rucinski, PharmD, CACP is a Clinical Pharmacy Specialist in the Anticoagulation Management Clinic at the Dana Farber Cancer Institute and a nationally board-certified Anticoagulation Care Provider.

Themio Papadopoulos, PharmD is an Advanced Practice Clinical Pharmacist at the Brigham and Women’s Hospital Anticoagulation Management Service.

*Originally published in The Beat – August 2021. Read the full newsletter here.