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Clinical Articles, Lead Article

NOAC advice for surgical patients

An overview of the major clinical trials and recommendations related to new oral anticoagulants, which aims to serve as a practical guide for their use in patients who require planned or emergency surgery, has been published recently in the British Journal of Surgery.1

Dr Aida Lai (Frenchay Hospital, North Bristol NHS Trust), and colleagues, searched the medical literature and analysed studies published between January 2000 and January 2014 that reported on the use of new oral anticoagulant drugs. “As these drugs are still relatively new in the market, knowledge about how they work and their associated bleeding risks are still limited in the medical and surgical community,” said Dr Lai. “Our review covers recommendation for the discontinuation of new oral anticoagulant drugs before surgical procedures and resuming of these drugs after procedures.”

The review also notes that because the drugs are eliminated by the kidneys, they require dose reductions dependent on a patient’s kidney function. Also, new oral anticoagulants are not recommended in patients with severe liver dysfunction and, because the three drugs have somewhat different properties, one of the drugs may be better suited to a particular patient than the others.

Screen shot 2014-05-28 at 14.50.47

Dr Aida Lai (Frenchay Hospital, North Bristol NHS Trust)

“It is anticipated that in the near future these drugs would replace warfarin to a large extent,” said Dr Lai. “Therefore our article is highly relevant to surgeons and any medical professional treating patients on these drugs.”

Speaking to BJC Arrhythmia Watch, Dr Lai said: “The development of new oral anticoagulants (NOACs) in recent years provides an attractive alternative to warfarin for stroke prevention in patients with non-valvular atrial fibrillation.  These drugs have demonstrated non-inferiority in efficacy compared to warfarin in major clinical trials, with a reduced risk of intracranial haemorrhages. Warfarin, although effective, has numerous limitations including drug-drug interactions and a narrow therapeutic index requiring frequent coagulation monitoring. NOACs have a rapid offset and onset and therefore there is usually no need for bridging anticoagulation with heparin in perioperative periods.”

“Although NOACs have the advantage of relatively short half-lives compared to warfarin, several issues still concern surgeons. Firstly, there is difficulty in measuring the anticoagulant effect of NOACs which poses problems in situations like patients undergoing emergency surgery and managing major or life-threatening bleeding complications. Prothrombin time and activated partial thromboplastin time are unsuitable for quantitative assessment for NOACs and may only be used for qualitative assessment for dabigatran and rivaroxaban. The coagulation assays for drug levels of NOACs are currently not readily available and sensitivities of reagents vary widely. Unlike warfarin whose effect can be reversed rapidly by prothrombin complex concentrates and vitamin K, no specific antidote exists for NOACs. It should also be noted that all NOACs require reduction of dose depending on renal function,” Dr Lai added.


1. Lai A, Davidson N, Galloway SW, Thachil J. Perioperative management of patients on new oral anticoagulants. Br J Surg 2014;101:742–9.

Published on: May 28, 2014

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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