Stop NOACS for surgery??

[Oldcarol]

I am scheduled for carpal tunnel surgery. Was told to stop apixaban 5 days before and 2 days after! I will have a heart attack thinking about being off that long. Anybody else having procedures and told to stop?

[rosyG]

Hi,

I have cut and paste the NICE guidelines for Apixaban and Surgery below

If you want to look google NICE guidance for stopping NOACS and surgery

Click on apixaban and scroll right through

I would suggest printing everything out and taking to whoever is advising you about when to stop and start

f the person needs to have surgery or any other invasive procedure, they may need to temporarily stop taking apixaban.

The decision to stop apixaban and when to stop it will depend on the person's risk of having a thromboembolic event and the bleeding risk associated with the procedure.

For procedures associated with no clinically important bleeding risk the procedure can be performed:

Just before the next dose of apixaban is due or

Approximately 18–24 hours after the last dose of apixaban was taken (apixaban should be restarted 6 hours later). This means one dose of apixaban may be missed.

For procedures with a low bleeding risk, apixaban should be stopped 24 hours before the procedure.

If the person has a creatinine clearance (CrCl) between 15–30 mL/min, apixaban should be stopped 36 hours before the procedure.

For procedures with a high bleeding risk, apixaban should be stopped 48 hours before the procedure.

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Bleeding risk

Treatments with 'no clinically important bleeding risk’ include:

Dental interventions such as; extraction of 1 to 3 teeth, periodontal surgery, incision of abscess, and implant positioning.

Cataract or glaucoma interventions.

Endoscopy without surgery.

Minor surgery (e.g. abscess incision and small dermatologic excisions).

Treatments with 'low bleeding risk' include:

Endoscopy with biopsy.

Prostate or bladder biopsy.

Electrophysiological study or radiofrequency catheter ablation for supraventricular tachycardia (including left-sided ablation via single trans-septal puncture).

Angiography.

Pacemaker or implantable cardioverter defibrillator (ICD) implantation (unless complex anatomical setting, e.g. congenital heart disease).

Treatments with 'high bleeding risk' include:

Complex left-sided ablation (pulmonary vein isolation; VT ablation).

Spinal or epidural anaesthesia.

Lumbar diagnostic puncture.

Thoracic surgery.

Abdominal surgery.

Major orthopaedic surgery.

Liver biopsy.

Transurethral prostate resection.

Kidney biopsy.

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[dedeottie in reply to rosyG]

I have printed out these and take them with me whenever I go for surgery. Most doctors are glad to read them and always follow the guidelines! Recently I had minor surgery on my eyelid. We had agreed that I would miss one dose of apixaban. He cauterised the wound and there was absolutely no blood but he still wanted me to miss the next few doses aswell. He suggested I could take asprin instead just to be safe. He had asked if 2 student doctors could be there for the procedure so I took it upon myself to educate all 3 of them ! Needless to say we all agreed by the end that I should continue taking apixaban. I should Add that there was no blood whatsoever. X

[robboian]

Hi Oldcarol. Yep been there and had to make the same difficult decision. You can probably understand why the surgeon wants you to stop the anticoagulant. I suspect that the surgeon would say that the statistical chance of a stroke over that few days is minimal. Great but not much consolation if you are the exception. I guess that it is a risk reward thing. If you need and want the surgery then take their advice. On the other hand you will need to make up your own mind about whether you want to go ahead. Good luck.

[Polski]

Are they giving you the same advice as they would for Warfarin, not realising that an NOAC works completely differently?

[Hidden]

I think the advice you have been given is not appropriate and this is an opportunity for some education for the surgical team.

Why do we not have advice along the lines of the NICE guidelines rosyG has provided printed on the leaflet we get with every packet of pills we collect? Or a separate sheet that says please give this to the surgeon / dentist / out of date ignoramus treating you. I'm copying and saving Rosy's helpful contribution.

My dentist says he doesn't require his patients to stop taking Rivaroxaban for tooth extraction.

[Oldcarol in reply to Hidden]

Thanks. I do fear my EP is outdated and only I can make that decision to stop them, but if half life of apixaban is only 12 hours seems like one dose is all I am going to miss. 5 days is unusual I think.

[MarkS]

The NICE guidelines need revising. Apparently a PVI ablation is regarded as high risk with Apixaban stopped 48 hours before. Recent studies have shown that this is poor practice, it should be continued throughout the ablation due to the microthrombi produced during the ablation. Without anti-coagulants these can lead to long term problems.

[rosyG in reply to MarkS]

Good point Mark but I suspect EPs will give more up to date advice than general surgeons so hopefully not a problem

[Oldcarol in reply to rosyG]

My EP is known to be the best here in KY but even he can get old and outdated I guess. Hopefully I won’t need him again.

[Oldcarol in reply to MarkS]

Not my EP evidently. May have to find me a new one.

[Oldcarol in reply to MarkS]

Thanks. Sorry to answer late. We r in different time zones. I will definitely look up new guidelines. And reconsider my EP.

[doodle68]

I would not stop anticoagulation for longer than is absolutely necessary if at all.

My body my choice, I fear a stroke far more than I fear postoperative bleeding.

[Mrspat]

I am having an operation on my tear duct later this month, anoperation which the surgeon says is “very bloody”. I have told by their cardiologist,who is not my cardiologist and who has never met me, that I should stop Rivaroxaban 3 days before and 1 day after the operation. Yesterday I cut my finger and was very surprised how long it took to stop bleeding.

[Hidden]

Hi Carol, I had a cataract operation on Monday , stopped my apixaban 4 days before, also go in for a nerve block injection in 2 weeks time so Doc said just to wait till both procedures have been done then to start again,

[Oldcarol in reply to Hidden]

Seems like 2 weeks is a long time. My risk factors are moderate. 70, sleep apnea(controlled) ablation last July with only occasional afib episodes lasting just minutes, but I still feel insecure being off apixaban that long. We will have to hope for the best outcome. Hope u have good success with your procedures. Mine isn’t crucial till I get so I can’t use my hand.

[caos52 in reply to Hidden]

Think I would call hospital and ask the consultant before stopping for 2 weeks. GP is just that .. general.

[Hidden]

It does to me old Carole, I have PAF, only 2 episodes in the last year and chads score 2 purely down to age and gender, my Doc doesn't seem to be worried, my nerve block injection is in my neck ( petrified ) it's done in theatre so definitely no anticoags. Good luck with your op. .

[Coco51]

I am having an infected cyst removed and have been told to stop the Apixaban the evening before and the morning of the surgery (so 2 doses) and start again the same day as the surgery in the evening. It was the same for my latest ablation. Previously when I had surgery and was on Warfarin I was told to stop it 4 days before hand and start asap afterwards. 7 off Apixaban does seem rather a long time. Worth querying. Good luck with the op. J x

[Oldcarol in reply to Coco51]

I had a cyst on my back also and was told the same thing! 5 days off before and 2 days after. I told them they were crazy! A cyst?? They weren’t going down to my spine!! I refused, the cyst opened on its own and healed well. Carpal tunnel is minor also and I have had one done and the other needs done as soon as I get it scheduled. I’m going to self-treat. Missing 2 doses is enough.

[Hidden]

When I've had surgery in past stopped anticoagulant and had low molecular weight heparin injections