Richmond’s Sinus and Allergy Specialists

When should I stop my anti-coagulation before surgery?

Anticoagulants are commonly prescribed to prevent blood clots in the heart, leg veins and lungs, especially in patients with a history of atrial fibrillation, artificial heart valves, deep venous thrombosis or pulmonary embolism.  Anticoagulants will increase the risk of bleeding with any surgical procedure.  The need for anticoagulation should be balanced against the risk of bleeding for any invasive procedure.  Simple procedures like ear tubes, nasal endoscopies, skin biopsies, laser treatments and even some minor skin surgeries have a very low risk of bleeding and can often be performed without discontinuing anticoagulation.  Major surgeries in the head and neck and surgeries involving the nose and tonsils have a higher risk of bleeding and should ideally be performed without anticoagulation.  The decision to stop anti-coagulation should be made jointly between the surgeon and the physician who is prescribing anticoagulation.

Aspirin

Aspirin and other nonsteroidal anti-inflammatory agents that impair platelet function have the longest half-life.  The body actually needs to produce new platelets to replace the ones that had been inactivated by the drug.  If possible, discontinue use of aspirin products  2 weeks before surgery.  Be cautious of aspirin-containing products such as Alka-Seltzer, BC powders, Bufferin , Excedrin, Fiorinal, and Aspergum.

NSAIDs

Nonsteroidal anti-inflammatory drugs such as Advil (Motrin, ibuprofen), Aleve (Naprosyn, naproxen), and Indocin (indomethacin) also inhibit platelet function and should be held for 2 weeks before surgery if possible.

Coumadin

Coumadin (warfarin) blocks the production of blood clotting factors.  It takes about 4-5 days for the effect to subside, assuming that the prothrombin time/INR is therapeutic.  Vitamin K is an anti-dote.  Coumadin is the most difficult anticoagulant to manage and close physician supervision is required.

Factor Xa inhibitors

Xarelto (rivaroxiban), Eliquis (apixaban), and Savaysa (edoxaban) inhibit blood clotting factor Xa.  They can be stopped 2-3 days before major surgery and held one day before minor surgery.  These can be resumed the day after surgery if there is no bleeding.

Pradaxa

Pradaxa (dabigatran) directly inhibits thrombin from activating the clotting cascade.  It can be held 2-3 days before major surgery and one day before minor surgery.  Pradaxa can be resumed the day after surgery if there is no bleeding.

Vitamins and herbs

Vitamin E and herbal supplements such as ginkgo, garlic and St. John’s wort can also increase the risk of bleeding.  Please discuss these with your surgeon.

This information is intended to be a guide only.  Before any surgery, discuss your anticoagulation needs with your surgeon and prescribing physician.  The risks of discontinuing anticoagulation may include death or serious disability due to stroke, heart attack, or pulmonary embolism.  These risks should be weighed against the benefit of surgery and in consideration for the risk of surgical bleeding.  For more information, see http://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants.