Narrator - Dr. Abel  00:00
Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions.

Narrator - ?  00:11
This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy.

Narrator - Dr. Abel  00:17
This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider.

Narrator - ?  00:27
And now on to the show.

Dr. Sean Kane  00:31
Welcome to HelixTalk, Episode 74 I'm your co host, Dr. Kane.

Unknown Speaker  00:35
I'm Dr. Schuman,

Dr. Khyati Patel  00:36
and I'm Dr. Patel, and the title of our episode today is taking a break perioperative management of anticoagulants. In this episode, we hope to accomplish discussing some of the factors that we consider in the management of various anticoagulants, especially around the procedures, and we hope to provide you a synopsis of what are some of these agent specific, pharmacokinetic and pharmacodynamic factors that would go into making recommendations for periprocedural monitoring.

Dr. Sean Kane  01:06
So Dr. Patel a this is a super relevant area for pharmacy to play a role. I get a ton of questions about anticoagulants, when to start stop, how to bridge things like that. So this is, for sure, a relevant topic. And for me, I learned best with a case. So would it be possible for you to kick us off with a great clinical case example?

Dr. Khyati Patel  01:25
Absolutely, this case actually is a real patient case that just happened to me last week in the clinic. So it's kind of like clinic. You have to play around with some of your hospital physicians and surgeon counterparts as well. The patient was a 55 year old African American female who was on Warfarin for recurrent VTE. Her last DVT was seven years ago, so we had her on Warfarin for that recurrent VTE prevention with a goal INR of 2-3. Her dose was pretty stable at 7.5 milligrams daily. However, what threw wrench in the process was that she was debilitated by bilateral OA related knee pain, and she was consulting with this rheumatologist who kept on giving her steroid versus an inter articular stero injections and NSAIDs, so, right? That's interactions with Warfarin and whatnot. But then she finally saw an ortho and ortho said, Okay, we're gonna take one knee at a time, and decided to do a left knee replacement first. So she's two weeks out, and she's coming to me telling me that, you know, we're going to have to do something about her Warfarin because she has a procedure in two weeks. So the question was, how do we develop this perioperative plan? And what I also knew that she was on 81 milligram aspirin for primary cardiovascular prevention.

Dr. Sean Kane  02:43
Now, Dr. Patel, before we get into it, I just think it's important to emphasize to especially students that may not be familiar with this topic, what are like some potential things that you might do to manage this patient in terms of what are some options? So like, for example, maybe we stop Warfarin and do a daily INR for a while, or maybe we stop Warfarin and then check INR in a couple days. Or maybe we stop Warfarin and never check INR and assume it's low enough, and then on top of that, maybe we give her something in the meantime that isn't as long acting as warfarin. Yeah.

Dr. Khyati Patel  03:14
So usually in those patients who are taking warfarin for treatment purposes, we stop warfarin based on warfarin's pharmacodynamic profile five days before, and then based on the risk of clotting, we put them on low molecular weight heparin, which is a parenteral anticoagulant — not as long acting as warfarin, shorter acting so you can turn the switch off, you know, 12 to 24 hours before the procedure. And then it's really up to the surgical team. They may have standing order for the INR to do right before the procedure, and they're ready with their, you know, emergent reversal agents, if that wasn't the case, but that's usually what we do.

Speaker 1  03:56
And then certainly, then there's other individuals, again, based upon some dialog that we sometimes will stop the warfarin and not bridge them, but continue them to hold for a number of days until the procedure and then restart it. And then you also have a few of those individuals that I think sometimes, maybe even we continue the anticoagulant indefinitely throughout the procedure, if we can. So hopefully we can do today is look at all those different scenarios and kind of come up with a continuum for risk and benefit and hold versus continue.

Dr. Sean Kane  04:23
So it sounds like a we got to have a plan well before the procedure. So probably at least a week out, we're thinking about, what are we going to do, regardless of what the actual plan is?

Dr. Khyati Patel  04:33
Absolutely and in this very organized clinical world nowadays, we have something called procedural or pre procedural physician visit, depending on the cardiovascular risk, the patients might be required to see a cardiologist to get a quote, unquote clearance for a procedure. So patients should be informed what exactly needs to be happening with their medications, including any kind of anti platelets or anticoagulants. Usually this visits are scheduled seven days before.

Speaker 1  05:00
Four Yep. And again, our facility, you know, it's that signing off from cardiology or the pre procedural checklist or worksheet that kind of triggers the consult of pharmacy or to their regular in or the provider who's providing the anticoagulation regimen. Let's go ahead and do this now. What do we do?

Dr. Khyati Patel  05:16
Yeah, and usually in these meetings or visits, what we are considering is whether we need to interrupt the anticoagulation or not. When do we need to interrupt the anticoagulation, whether we need to bridge or not, as we were just talking about, if we are bridging, how do we bridge? And when do we restart the patient on the anticoagulation? Now, when to restart is really dependent on patient stability post procedure. So a lot of the time that's handled by the surgery team or handled by the inpatient hospital team, but at least we should have an idea so we can let the patient know that, you know, this is the period of time where their anticoagulation might be restarted.

Dr. Sean Kane  05:55
What I always find really fascinating about this whole topic is the amount of individualization that goes on in terms of the this decision making process. So one thing is, what kind of procedure are they having, and what is the actual bleeding risk for that procedure? How worried are we about that they may have some residual anticoagulation, or even if we continue it the whole time? Is that a big deal?

Dr. Khyati Patel  06:18
Absolutely, and many when we're dealing with this bleeding risk. We're looking at bleeding risk from two different perspective, surgery based bleeding risk. So that's like given no matter what the patient is. But then we're also looking at patient-specific bleeding risk that can be calculated by a HAS-BLED calculator, right? So the AHA, ACC 2017, statement, by the way, we have a citation posted for that resource on the HelixTalk website. But that particular guidance looks at both type of bleeding risk versus the ACCP 2009 chest guidelines recommend the bleeding rates assessment based on the procedure related bleeding, and not really the individual bleeding. So again, like you said, Dr. Kane, we need to individualize this.

Dr. Sean Kane  07:04
So in terms of some of those procedures, you know, for me, the thing that comes to mind in terms of very, very high risk procedures are going to be anything that involves the brain or the spinal cord — neurosurgical procedures — and then also cardiac surgery. So any open heart surgery, valve operations, CABG, or bypass grafts, things like that. That's going to be a fairly high risk for bleeding.

Speaker 1  07:27
And again, that seems fairly intuitive these organs that you know, in the case of the brain, again, we have a closed space. Pressure is bad. Bleeding in these areas is obviously a very bad thing. All right, what else we got? So we got kind of our very obvious one, something like, you know, neurologic procedures, cardiac moving down what's what would be the next one, Dr. Patel,

Dr. Khyati Patel  07:44
then we move on to the second category of risk, which we define as high risk, things like, you have abdominal aneurysm repair procedures. So these are major vascular procedures, certain urologic procedures (things like prostatectomy), thoracic procedures such as lobectomy, and even lower limb surgeries like knee replacement or hip replacements are considered high-risk procedures. Certain other procedures, like pacemaker replacement is also in this high risk procedure. And then some of the elective, invasive procedures include certain biopsies, variceal endoscopy, meaning it's an endoscopy, but there's likelihood of banning those varices that has higher risk of bleeding. And then, if there is a colonoscopy, and there are obviously evidence of polyps, and the polyps are going to be clipped, this is considered a high risk procedure, and

Dr. Sean Kane  08:39
a lot of this, if you think about it. In addition to like, bleeding in your brain is bad, a lot of these deal with either it's a very vascular space where bleeding is common, or it's a place where you can't put pressure on it if you do bleed. So for example, if you have a variceal hemorrhage because of your procedure, you can't stick your arm in someone's esophagus and hold down a bleeding varix. So it deals both with propensity to bleed, but also inability to tamponade off a bleed if it does occur.

Speaker 1  09:07
And I think again, one thing also to point out is the idea that there is going to be some, again, some variance back and forth, because it's a lot of these procedures. It's not just a procedure, but how it's done and alone. We talked about prostatectomy, for example, a couple times in our clinic, it's been dependent, you know, we can send somebody to another facility that does a laser resection of the prostate, which, because the cauterization inherent in doing the laser procedure, much lower risk versus somebody who uses a scalpel and does a Terp or bladder resection, again, using a little bit more, you know, maybe outmoded or more or less refined techniques. And so even there, there's some variance among our providers as far as what they feel safe with based upon how they do. And so that's where really we have what's written out. And then the other thing too is talking to your providers about, you know, what are they doing? What has been their experience as they do these procedures?

Dr. Khyati Patel  09:53
And that's actually a really good point to provide. We're looking at just a list of the name of the surgery the patient is going to undergo on a chart. We have no idea what route or method the surgeon wants to use. So again, that emphasize the inter professional collaboration and designing any kind of recommendations, all

Speaker 1  10:14
right, so kind of moving down from our high risk to some of our intermediate again, looking at other fairly significant surgeries. But as Dr. Kane, as you pointed out, maybe in a less vascularized region or an area where we do have some interventions we can perform, so intra abdominal procedures, orthopedic procedures, number of them can be considered intermediate risk, as well as potentially on lung, liver biopsies and abscess drainages, again, that we have different ways that we can address the bleeding should it occur, and maybe a less vascularized area,

Dr. Sean Kane  10:43
and then a low risk would be something like a laparoscopic procedure, cholecystectomy, the removal of the gallbladder, especially if it's laparoscopic angiography, so going to the cath lab to look at your coronary blood vessels, and then a colonoscopy or endoscopy, these are fairly low risk kind of moving forward some elective procedures, like a biopsy of your bone marrow, thoracentesis or paracentesis, we're pulling fluid out from around the lung or in the belly. And then there's kind of this gray area between certain kinds of dental eye and dermatologic procedures. They're either low risk or very low risk, depending on the procedure itself. Yeah.

Speaker 1  11:17
Like, for example, according to some that I've read, you know, something like a dental extraction may be considered low but something like a cleaning or a filling is probably something that's very, very or minimal risk.

Dr. Khyati Patel  11:27
And I get these phone calls all the time from dentist offices or the patients saying, Hey, I'm getting my cleaning done. Do I need to stop warfarin? No, you don't. You know I'm getting my single tooth extraction. Do I need to do anything? No, but things that have more manipulation with the jaw, more like orthodontic type procedures that might be in the low or intermediate risk category.

Dr. Sean Kane  11:49
So clearly, bleeding is a huge deal because we're giving an anticoagulant to these patients. The opposite, of course, is true, that they're on the anticoagulant for a reason, right? So we're worried about clotting or thromboembolic risk because of potentially withdrawing the anticoagulant that was giving them the protective effect from the clotting that they were at risk for, right?

Dr. Khyati Patel  12:10
And then ACCP 2009 guidelines do a really good job of establishing the thromboembolic risk based on why we are treating the patient. So it could be based on the fact that patient has a valve or patient has a higher chat score. So let's break it down. The categories of this risk are high, intermediate and low, and some of the things that are included in the high risk would be obviously mechanical valve in the mitral position, or if they have cage ball or tilt and disc type of aortic valve, or if they have any kind of rheumatic valve conditions or heart disease to begin with.

Dr. Sean Kane  12:46
And really, this shouldn't be that big of a surprise, being at the top of our list, given the many mechanical heart valves we actually run their INR goals two and a half to three and a half for a reason, they're at very high risk for clotting,

Dr. Khyati Patel  12:57
and if the patient had a VTE event very recently, they're going to be also put in the high-risk category. This timeline is very important. They say within three months of having a recent VT, they're considered high risk. And if it's stroke, we're looking at a six month period since the last stroke. Obviously, patients who have accumulated higher Chads score, five or six with atrial fibrillation are considered high risk as well. If you know patient's history, and if they've had a clot because we interrupted the anticoagulation, then these patients are going to be considered high risk. So these kind of things should be documented in the patient's chart, so we kind of base off of the patient's history. This is a way to individualize it, and then obviously we have some patients taking anticoagulants because of thrombophilias. Even among the thrombophilias, we do have categories of high versus intermediate. So things like protein C or protein s deficiency or anti thrombin deficiency are going to be considered severe thrombophilias.

Dr. Sean Kane  13:56
And in terms of that intermediate risk of thromboembolic or cladding risk. This is going to be patients with mechanical heart valves in the aortic position, which isn't as severe in terms of cladding risk as the mitral position, or those with a which has two score in the three to four range, with afib, obviously, again, thinking about patient history, if they've had recurrent vte, so multiple VTEs, which is a DVT or a PE or they had a VT within the past three to 12 months. Again, less than three months was the really severe time. Three to 12 months is this intermediate risk. They have active cancer. That's a huge risk factor for VTE and active being that they've been treated within the last six months, or they're undergoing a palliative care regimen. And then finally, they have factor five Leiden mutation or prothrombin gene mutation, that would also put them in this kind of intermediate risk category.

Speaker 1  14:47
And so that compares, I believe, to our third category, which is gonna be our lower risk. And this individuals that have had VT, but it's, you know, years ago, or at least, bare minimum of a year before, or those with atrial fibrillation and no major. Chance to score based stroke risk. So maybe they have a score of zero to two and no history of stroke or TIA.

Dr. Khyati Patel  15:05
So that's step one of the patient assessment is evaluating patients thromboembolic and bleeding risk. Now let's say patients on one of these agents, then we have to move forward to agent based recommendation. So most of these recommendations are coming from ACCP, 2009 guidance, as well as the HA ACC 2017 guidance. Just to note to our listener, both of these citations are posted on our website, but keep in mind the 2017 ha ACC guidance is only in patients who have non valvular atrial fibrillation, and it's a lot of that comes from the bridge trial data that we recorded in our episode 42 so if you would like to refresh your memory, we encourage you to listen to that as well.

Dr. Sean Kane  15:49
So the first agent that we'll talk about is heparin. So Heparin, at least on the inpatient side, is really nice, because it has a fairly fast onset and offset. The half life is about an hour, so you get to steady state and somewhere between four ish hours, or a little bit longer than that, if you have someone with a lower bleeding risk, if you turn off a heparin infusion four hours later, they're good to go, in terms of whatever you want to do to them, that they're no longer heparized for a high risk procedure, you may wait between four and six hours, depending, again, on the acuity of the procedure, potentially something like their hepatic function and things like that that could impact their half life. Their half life. But just to put it into perspective, and at Condell, where I work, when we have post in my patients that are getting Heparin, basically waiting to have open heart surgery for a cabbage typically, if it's the first case, we'll stop the heparin at 4am and they'll go to the case at 8am and they'll probably open them between eight and nine. So this is very common that we'll use Heparin, because it's so versatile in terms of its timeline, it gives you a lot of flexibility.

Speaker 1  16:47
Yeah, one of the things we'll look at, though, is, you know, it's a great option again, for you have individuals that we can get that time to be able to put them in the hospital and undergo this but there's a lot of individuals, especially with a lot of elective procedures, who they either at time of convenience sake, say we're going to put you in for these additional hours. It's not feasible. So then we have to look at, you know, what else? What else is out there? And so we have a few other options. Again, we can also do subcutaneous heparin, especially if it's VTE prophylaxis for a hospitalized patient. Again, similarly to Dr. Kane, which you mentioned, holding six to eight hours before to allow the drug to clear out by the procedures, again, we're kind of toning that line, get the drug in, clean it out, and now we can go ahead with the procedure with a minimal additional bleed risk.

Dr. Khyati Patel  17:27
Another commonly used parenteral anticoagulant is enoxaparin. It can be dosed therapeutically or prophylactically. For therapeutic twice‑daily dosing (1 mg/kg every 12 hours) we typically hold one dose before the procedure. For once‑daily therapeutic dosing (1.5 mg/kg once daily) we often give half the dose the day before the procedure. So usually, again, it's based on the bleeding risk, but anywhere between 12 to 24 hours is when we stop the therapeutic enoxaparin, and

Dr. Sean Kane  18:01
then for that prophylactic, typically, we're just holding the morning dose. So if they have a procedure that day, you'll just not give them the dose that morning. If it's a moderate or high risk procedure, you're going to wait between 12 and 24 hours, again, based on a number of different factors. And of course, we should kind of mention that this is highly reliant on the patient's renal function. So it's not uncommon that I'll have patients on Lovenox who are admitted to the ICU with acute kidney injury. Maybe they normally would get the bid dosing, but now they're absolutely not good candidates for it. Their half life is going to be a lot longer. Therefore we have to wait a lot longer before we can do a thoracentesis or some other procedure on them, because they're going to retain that drug for longer if their kidneys aren't working

Dr. Khyati Patel  18:41
as well. And interestingly enough, you said that because the AHA/ACC recommendation calls for checking patients' anti-Xa level before the procedure — though it's not clear what's the real clinical utility or how many institutions actually check anti-Xa levels. But things like obesity, things like, you know, creatinine clearance is going to be factored in as to how fast this drug is cleared.

Dr. Sean Kane  19:04
Or I can tell you, at least at my facility, an anti-Xa level takes about a day to come back. So if you do wait that day and it comes back high, your result is literally a day later. So it really does depend on availability of the anti‑Xa assay and how you interpret it — if it's detectable but at the low end of therapeutic for prophylaxis, is that acceptable? Do you want to wait longer? We don't really have good data to help direct that, but obviously, if it's zero, you're good to go.

Dr. Khyati Patel  19:34
Yeah, absolutely. Some of the not-commonly-used parenteral anticoagulants, such as fondaparinux and argatroban, are handled based on creatinine clearance, once again. So they're holding it will depend on the bleeding risk of the procedure, whether the dose is therapeutic or not, if it's prophylaxis, you know, maybe you just hold the day day before, versus if it's therapeutic, then you have. Consider the patient's creatinine clearance as well.

Speaker 1  20:02
So I think a good summary at this point is that subcutaneous or IV anticoagulants all have a fairly short half-life, and thus the pre-procedural dose hold is in hours, not days; the holding time depends on whether the dose is therapeutic versus prophylactic. Again, we've talked a little bit about the role of kidney function. Again, the nice thing here is that we're trying to, kind of, you know, create this little short bridge, literally, as the word is, to throw it in there and to provide some additional anticoagulation without adding that additional bleed risk. And so I think we do have, though, a number of oral anticoagulants. And I think for most of the listeners, this is going to be the medications that they're most familiar with. And so, Dr. Patel, what do we what is the current stance as far as Warfarin and the doacs and Peri procedural management?

Dr. Khyati Patel  20:46
Absolutely, the Warfarin is something that you're going to see, still very commonly see in some of the outpatient management. And so one thing we need to remember is warfarin's PK/PD — the pharmacokinetic and pharmacodynamic parameters — which mean warfarin takes a while to get to therapeutic effect and has a longer duration. So keep those PD parameters in mind while you're designing this periprocedural recommendation for most low, very low risk procedures, the recommendation is to hold for zero days, meaning not hold it all or hold it for maybe a day before the procedure. So example of this include a single tooth extraction or dental cleaning procedure. Most of the time, the recommendation is to continue warfarin, and if possible the dental office should use local prohemostatic agents such as aminocaproic acid.

Speaker 1  21:35
And again, this is one where a number of times, you know, I've had dialysis providers, and sometimes, you know, it's sometimes we can a give and take, or a little bit of a bridge providers feel comfortable again. Can we do a day bridge safely? Probably, so sometimes I have, you know, really push for just continuing the medication, but a number of times, again, is if the provider has more comfort knowing the procedure they're doing, I'm willing to concede, you know, a day hold may be safe without compromising the individual in terms of clotting potential,

Dr. Sean Kane  22:02
then really after that, in terms of warfarin. It again, obviously it's based on the bleeding risk of the procedure. So if it's a lower risk procedure, going to hold between one and three days, moderate to high risk procedure hold for five days, and maybe even bridge, depending on the patient's clotting risk. And you know, Dr. Patel, as you mentioned, we did cover this specifically in Episode 42 which you can listen to at HelixTalk.com where we talked about the bridge trial, which was basically the question of, do you give them a parenteral anticoagulant during this bridging procedure or not?

Dr. Khyati Patel  22:34
And then we also covered certain common rules or mechanisms of how we design a bridging regimen? Is it just pre procedural? Is it pre and post? Do we do therapeutic, low molecular weight heparin, or do we do prophylactic? And this is all going to be dependent on patients clotting and bleeding risks.

Dr. Sean Kane  22:53
So warfarin is no longer the only kid in the game in terms of oral anticoagulants. Now that DOACs are on the market, that changes the complexity of the outpatient scenario. So what do we think about DOACs in terms of perioperative anticoagulation?

Dr. Khyati Patel  23:07
So again, we have to remember their pkpd parameters are different than warfarin. They're kind of like an on and off switch. And so we definitely don't employ any type of low molecular weight heparin bridging — not even for dabigatran. I should mention that when dabigatran was studied for initial treatment, a parenteral lead-in was used, but we do not bridge dabigatran for procedures. We also do not use a parenteral bridge when stopping dabigatran for procedure-related management. The global idea here is generally for a low risk procedure, we hold it for a day before, but for all the other procedures like high risk or moderate risk, the recommendation for doacs is going to be dependent on patients creatinine clearance.

Dr. Sean Kane  23:50
So Dabigatran was first to the market, but it also has the most complex bridging algorithm, if you will, you're going to hold somewhere between two doses or 24 hours, all the way up to five days worth of Dabigatran based on renal function and risk of the procedure. And I would always, always take a look at the package insert, because it's going to have a lot of this specifically in there. With the caveat that when a pharmacist such as myself approaches a provider and asks, Is this a moderate or high risk procedure. They may not know that answer, because that's a very subjective question. So sometimes I will discuss with the provider, and I'll say something like, you know if, if you perceive the bleeding risk to be fairly high, we can hold all the way out to 48 hours, but if you don't think the bleeding risk is as high based on patient specific variables, maybe one to two days would be appropriate more often than not, the decision to do it, at least in the ICU, is based on how bad do they need to do the procedure, and if they want to do it right now or as soon as possible, they're willing to take a slightly higher bleeding risk, as long as you provide that range of this is a reasonable range for that procedure. Sure I was that it's

Speaker 1  25:00
interesting, because, you know, in mind, more in the outpatient setting, I sometimes have more of the opposite, where a lot of times the providers are very skittish about bleed risk and much more willing to hold a medication for a while, and yet at the same time, then they're more apt to, I think, still do bridging, which then provides a different kind of bleed risk. And so there's been kind of this give and take that I've observed, and so again, trying to work to kind of use some of the bridge trials, some of that data, to justify, okay, we're kind of out of this bridging era, but the same time, as you said, you know, knowing a little bit more about the procedure and deferring to that individual who does know, kind

Dr. Khyati Patel  25:33
of summarizing what you both said, too. You know, nowadays we have patients going to a day surgery center that is an independent surgery center of the patient's primary hospital or physician's office. So like, if they don't have any data available as to what has happened to the patient in past, what are their risk and stuff, they may really not get a full picture. So again, this is truly an interdisciplinary approach in deciding what exactly patient needs in terms of monitoring and management.

Dr. Sean Kane  26:04
And just to reiterate one additional point, with renal function, many providers don't appreciate how important that is for the duration of holding. So it's not uncommon that providers will just memorize the bigger trend I hold for 48 hours, when that's really not the whole scope of the scenario, and that's really where a pharmacist can play a critical role in saying, well, actually they have way worse renal function than than they had two days ago. Therefore, XYZ is what we should do for our decision to hold the anticoagulant.

Dr. Khyati Patel  26:34
And you brought up a really good point. Is that patients who are on an outpatient basis most likely will have more stable type of renal functions versus patient population you deal with in the ICU have frequently changing renal function. So your decision today is one thing, but tomorrow, if there's synchrony and it's different, you're going to have a completely different decision altogether.

Speaker 1  26:54
And so we usually take again if the biggest trend is being the one that has the most, I guess, impact from renal function, moving on to the two other anticoagulants. So rivaroxaban, again, is an example where renal function matters. Depending on whether somebody has creatinine clearance >50 versus <30, and depending on the procedure, recommendations range from holding one dose (a 24‑hour anticoagulation‑free period) up to holding for five days. And so again, be sure to read into this. There's a number of these factors, but based upon those, you know where they fit into that act those axes, you can have a pretty good idea.

Dr. Khyati Patel  27:36
And then the other DOACs, like apixaban and edoxaban, follow similar rules: look at creatinine clearance and procedural bleeding risk; holding periods range from 24 to 72 hours depending on the agent. Consult the prescribing information. Note that recommendations are based on Cockcroft‑Gault–calculated creatinine clearance, not the eGFR that appears on a basic metabolic panel. So you have to bring out your calculator and do this calculation.

Dr. Sean Kane  28:15
So clearly, looking at the package insert is really important for these. And again, to kind of summarize all of the doacs, Dabigatran and rivaroxaban you're holding between one and five days. Edoxaban and apixaban, you're holding between one to two, maybe a third day. So those agents that came out a little bit later, typically you don't have to hold them as long. But again, it depends on all of these other factors. So in terms of perioperative anticoagulation, it's not just about warfarin, doacs and other anticoagulants. We also have anti platelet therapies, and we also have to think about when to actually resume the stuff after the procedure. And given the complexity of this, we're actually going to extend this into a second part. So part two will be the next HelixTalk episode. We're going to stop right here, just covering bleeding risk, clotting risk and holding some of these agents, the specifically the anticoagulants. And again, we'll cover the anti platelets and when to resume at our next episode.

Dr. Khyati Patel  29:10
So rounding up the summary for this episode, we started out with making sure that we assess patients bleeding risk as well as the clotting risk, and make sure that we individualize the approach, even though we have all these guidances and recommendations available.

Speaker 1  29:26
And so the other the one on one, is looking at the medication itself and the holding period really needs to depend upon the pharmacodynamic and kinetic properties that we know of the individual agents, the half lives of it, the duration of the antiplatelet effect. For example, you need to factor those things in, along with those patient specific

Dr. Sean Kane  29:42
factors too. Then the third key point here is that this is not a one man band. This is an interdisciplinary approach in terms of this entire process. So the surgeon has to be involved in terms of the timing, figuring out the bleeding, risk of the procedure, specialists, maybe even an. Inpatient anticoagulation team, clearly the patient or the patient's caregiver, everyone has to be on board in terms of figuring out, when do we stop the agent based on all of the factors that we've discussed and based on the procedure risk itself. So with that, I think that wraps it up nicely. Be sure to listen to HelixTalk, Episode 75 where we continue the topic of perioperative anticoagulation. Notes from today's episode are available at HelixTalk.com (episode 74) where we have the 2009 ACCP Chest guidelines, as well as the 2017 AHA/ACC guidelines, more specific for nonvalvular atrial fibrillation. So with that, I'm Dr. Kane, I'm Dr. Schuman,

Dr. Khyati Patel  30:39
and I'm Dr. Patel, and as always, study hard.

Narrator - Dr. Abel  30:42
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Narrator - ?  30:53
suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.