Using New Oral Anticoagulants in Patients Undergoing Major Orthopedic Surgery

Four new oral anticoagulants (NOAC), apixaban, rivaroxaban, edoxaban, and dabigatran, are now available in the USA; however, only apixaban and rivaroxaban are FDA approved for the prevention of venous thromboembolism following orthopedic surgery. Apixaban, rivaroxaban, and edoxaban’s anticoagulant activity can be measured using a chromogenic anti-factor Xa assay but there is no widely available means of measuring dabigatran blood levels. None of the NOAC has an antidote. Dabigatran is 80 % renally excreted, and patients with atrial fibrillation taking dabigatran for stroke prevention should stop the drug 4–5 days prior to major orthopedic surgery. Apixaban, rivaroxaban, and edoxaban should be held for 48 h preoperatively in this setting.