====== Anticoagulation discontinuation ======

^ Feature | **Anticoagulation Discontinuation** | **Antiplatelet Therapy Discontinuation** |
| **Definition** | Stopping the use of anticoagulants, which prevent clot formation by inhibiting coagulation factors in the clotting cascade. | Stopping the use of antiplatelet agents, which prevent platelet aggregation and thrombus formation. |
| **Common Drugs** | Warfarin, Heparin, LMWH (e.g., Enoxaparin), Direct Oral Anticoagulants (DOACs) (e.g., Apixaban, Rivaroxaban, Dabigatran). | Aspirin, Clopidogrel, Prasugrel, Ticagrelor, Dipyridamole. |
| **Primary Indications** | Stroke prevention in atrial fibrillation, venous thromboembolism (VTE) (DVT/PE), mechanical heart valves, hypercoagulable states. | Prevention of arterial thrombosis in coronary artery disease (CAD), stroke, peripheral arterial disease (PAD), post-stent placement. |
| **Mechanism of Action** | Inhibits coagulation factors in the clotting cascade, reducing fibrin clot formation. | Inhibits platelet aggregation by targeting platelet activation pathways (COX-1 inhibition, P2Y12 receptor blockade, etc.). |
| **Discontinuation Risks** | High risk of thromboembolism (stroke, DVT/PE, mechanical valve thrombosis) if stopped abruptly. | High risk of arterial thrombosis, myocardial infarction (MI), and stent thrombosis (if recently placed). |
| **Bridging Considerations** | Often requires bridging (e.g., switching from Warfarin to LMWH before surgery). DOACs usually do not require bridging. | Usually no bridging required unless very high risk (e.g., recent coronary stent or stroke). |
| **Surgical Considerations** | Discontinuation timing depends on drug half-life and renal function. Warfarin may need stopping 5 days before surgery, DOACs 24-48 hours. | Discontinuation depends on bleeding risk vs. thrombosis risk. Aspirin is often continued, but P2Y12 inhibitors (e.g., Clopidogrel) may need to be stopped 5-7 days before surgery. |
| **Reversal Agents** | Vitamin K (Warfarin), Protamine (Heparin), Idarucizumab (Dabigatran), Andexanet alfa (Apixaban/Rivaroxaban). | No specific reversal agents, but platelet transfusion may be used in emergencies. |
| **Long-Term Discontinuation Considerations** | Often requires alternative therapy or monitoring for clot risk. | Stopping therapy inappropriately can lead to major cardiovascular events, especially in patients with recent acute coronary syndrome or stent placement. |


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see [[Direct Oral Anticoagulant]]


Warfarin (stop at least 5 preoperative days), and Xa inhibitors (Eliquis (Apixaban: stop for 2 days) and Xarelto (Rivaroxaban: stop for 3 days));  The anti-platelet aggregates include: Aspirin/Clopidogrel (stop >7-10 days preoperatively). The multiple NSAIDs should be stopped for varying intervals ranging from 1-10 day
((Epstein NE. When to stop anticoagulation, anti-platelet aggregates, and non-steroidal anti-inflammatories (NSAIDs) prior to spine surgery. Surg Neurol Int. 2019 Mar 26;10:45. doi: 10.25259/SNI-54-2019. PMID: 31528383; PMCID: PMC6743676.)).

===== Apixaban Discontinuation =====
[[Apixaban Discontinuation]]