Insight into the perioperative management of direct oral anticoagulants: concerns and considerations

ABSTRACTIntroduction: Direct oral anticoagulants (DOACs) have gained momentum in recent years in patients requiring anticoagulation for the prevention and management of venous thromboembolism and thromboembolic events caused by atrial fibrillation. The use of these agents involves potential bleeding complications, particularly during invasive procedures. With increasing use of DOACs, adequate knowledge regarding the perioperative management of patients on DOACs has become indispensable.Areas covered: This review covers the indications, mechanism of action, and pharmacokinetics of DOACs and their management in different perioperative settings based on various current guidelines and practices. The role of bridging therapy with heparin and the recently developed reversal agents are also discussed.Expert opinion: The perioperative management of DOACs is influenced by drug pharmacokinetics, potential comorbidities of the patient and perioperative thrombotic and bleeding risk. In low bleeding risk and minor pro...