Direct oral anticoagulant levels at time of elective surgery

Camilleri, E.; Shahbabai, P.; Rad, M.; Huijzer, C.A.; Huisman, M.V.; Dorp, E.L.A. van; ... ; Rein, N. van (2026)

Article / Letter to editor

Question: What proportion of patients have elevated residual direct oral anticoagulant (DOAC) levels before an elective procedure when discontinuing treatment according to a standardized protocol (1 day before moderate bleeding-risk procedures and 2 days before high bleeding-risk procedures, with adjustments based on the patient's kidney function)?

Findings: In this cohort study of 257 patients, 7.6% had elevated DOAC levels of 30 ng/mL or higher before the procedure. Among those receiving apixaban, this proportion was higher (13.6%).MeaningThese results suggest that the standardized interruption protocol is associated with DOAC levels below 30 ng/mL, although the proportion of patients with levels of 30 ng/mL or greater was higher among those receiving apixaban.This cohort study estimates the proportion of patients undergoing elective surgery who have elevated DOAC levels at the time of the procedure.

Importance: Before elective surgery, direct oral anticoagulants (DOACs) are discontinued following a standardized protocol. However, this could result in insufficient lowering of DOAC levels that could increase bleeding risk.ObjectiveTo estimate the proportion of patients with elevated DOAC levels at the time of elective surgery, evaluate factors associated with DOAC levels, and examine associated blood loss.

Design, Setting, and Participants: This cohort study (DOAC Level Prior to Incision [DALI]) assessed adult patients prescribed a DOAC (apixaban, dabigatran, or rivaroxaban) for any indication and at any dose, undergoing an elective procedure requiring DOAC interruption between May 27, 2018, and February 25, 2024, at 2 Dutch hospitals.

Exposure: Standardized interruption protocol (1 day before moderate- and 2 days before high bleeding-risk procedures) with interruption adjustments for the patient's kidney function.

Main Outcomes and Measures: Blood was drawn immediately before surgery to determine DOAC levels (by liquid chromatography-mass spectrometry). Proportions of preoperative DOAC levels of 30 ng/mL or higher and their 95% CIs were estimated, stratified by DOAC type and surgical bleeding risk. Factors associated with DOAC levels were identified through multivariable linear regression. Surgical blood loss and 30-day postoperative complications were described according to DOAC concentrations.

Results: The study was terminated after including 257 patients (100 receiving apixaban, 100 receiving rivaroxaban, and 57 receiving dabigatran due to the slow inclusion rate of those receiving dabigatran; median [IQR] age, 72 [66-78] years; 173 male [67%]); 212 patients (82%) underwent a high bleeding-risk operation. Preprocedural DOAC levels were 30 ng/mL or higher in 7.6% (95% CI, 4.9%-11.6%) of patients. Dabigatran and rivaroxaban had similar proportions, whereas 13.1% (95% CI, 7.8%-21.2%) of patients treated with apixaban had levels of 30 ng/mL or higher. Treatment with apixaban, decreased kidney function, and a shorter interruption time were associated with higher levels. Surgical blood loss (median [range], 0 [0-4250] mL) was not associated with DOAC levels. Twelve patients (4.7%; 95% CI, 2.7%-8.0%), who all had DOAC levels less than 30 ng/mL, experienced major bleeding.

Conclusions and Relevance: In this cohort study, most patients following the current protocol had DOAC levels less than 30 ng/mL, although the proportion of patients with elevated levels was higher for apixaban. Preoperative DOAC levels were not associated with blood loss during surgery.

• All authors: Camilleri, E.; Shahbabai, P.; Rad, M.; Huijzer, C.A.; Huisman, M.V.; Dorp, E.L.A. van; Visser, L.E.; Guchelaar, H.J.; Cannegieter, S.C.; Rein, N. van
• Date: 2026-02-04
• Journal: JAMA Network Open
• Volume: 9
• Issue: 2
• DOI: doi:10.1001/jamanetworkopen.2025.55875