DOACs Contraindicated with High-Risk Gastric Procedures

Contraindications Based on Renal Function and Procedure Risk

Dabigatran is specifically contraindicated in patients with creatinine clearance <30 mL/min undergoing high-risk gastric procedures 1
All DOACs (apixaban, rivaroxaban, edoxaban) are not recommended in patients with creatinine clearance <15 mL/min undergoing high-risk gastric procedures 1

For patients with creatinine clearance >80 mL/min, the American College of Gastroenterology recommends discontinuing dabigatran 2 days before high-risk gastric procedures 1, 3
For patients with creatinine clearance 50-80 mL/min, the American College of Gastroenterology recommends discontinuing dabigatran 3 days before high-risk gastric procedures 1, 3
For patients with creatinine clearance 30-50 mL/min, the American College of Gastroenterology recommends discontinuing dabigatran 4 days before high-risk gastric procedures 1, 3
For apixaban, rivaroxaban, and edoxaban, the American College of Gastroenterology recommends discontinuing 2 days before high-risk gastric procedures for all creatinine clearance levels >15 mL/min 1, 2

The American Society for Gastrointestinal Endoscopy recommends delaying all DOACs for at least 48 hours after ERCP with sphincterotomy due to increased risk of post-procedural bleeding 4
Patients with gastrointestinal malignancies should avoid DOACs due to significantly increased bleeding risk, particularly with intact intraluminal tumors, according to the American Cancer Society 5

The American College of Cardiology recommends resuming DOACs up to 48 hours after high-risk endoscopic procedures, depending on the perceived bleeding and thrombotic risks 2, 4
The decision to restart anticoagulation should balance the risk of post-procedural bleeding against the risk of thromboembolism, according to the American Heart Association 4

For severe bleeding during gastric procedures, temporary drug withdrawal may be sufficient due to the short half-lives of DOACs, according to the American College of Gastroenterology 6, 7
For life-threatening bleeding, specific reversal agents may be considered: idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors (rivaroxaban, apixaban, edoxaban), as recommended by the International Society on Thrombosis and Haemostasis 8

Bridging therapy with heparin when interrupting DOACs is generally not recommended as it may increase bleeding risk without reducing thromboembolism, according to the American College of Chest Physicians 6, 7
The Dresden DOAC registry showed heparin bridging for patients on rivaroxaban led to significantly higher rates of major bleeding compared to no bridging (2.7% vs. 0.5%, p=0.01), as reported by the European Society of Cardiology 6