Direct Oral Anticoagulants: An Update on Monitoring and Antidotes for the Perioperative Physician

The purpose of this review is to update the clinician on assessing and reversing the effects of direct oral anticoagulants (DOACs) in the perioperative period.

Traditional coagulation tests such as the PT and aPTT are not recommended to determine clinically significant effects of DOACs. Instead, the dilute thrombin time and chromogenic anti-Xa level can be used to guide the need for reversal of direct thrombin inhibitors and Factor Xa inhibitors respectively. Additionally, point of care assays such as viscoelastic testing and urine screening are under investigation. Current reversal strategies include the use of idarucizumab, andexanet alfa, and prothrombin complex concentrates prior to emergent surgery that cannot be delayed for DOAC effects to dissipate.

Given their relatively short half-lives, regular monitoring of DOACs is not needed, but perioperative physicians should be aware of available tests for determining the need to emergently reverse their effects.