Internal and Emergency Medicine

, Volume 13, Issue 7, pp 1029–1036 | Cite as

The vexed question of whether or not to measure levels of direct oral anticoagulants before surgery or invasive procedures

  • Armando TripodiEmail author
  • Francesco Marongiu
  • Marco Moia
  • Gualtiero Palareti
  • Vittorio Pengo
  • Daniela Poli
  • Domenico Prisco
  • Sophie Testa
  • Maria Zanazzi


Direct oral anticoagulants (DOAC) possess high bioavailability, and their anticoagulant effect is more predictable than that of vitamin K antagonists, hence they do not require routine dose adjustment based on laboratory testing. However, there are circumstances when laboratory testing may be useful, including patients who need to undergo surgery or invasive procedures. Most guidelines state that patients on DOAC may safely undergo surgery/invasive procedures by stopping anticoagulation for a few days before intervention without testing if renal function is within normal limits. This review article discusses the pros and cons of measuring (or not measuring) DOAC levels before surgery/invasive procedures by a multidisciplinary team of experts with different background, including the thrombosis laboratory, clinical thrombosis, internal medicine, cardiology and nephrology. The conclusion is that measuring DOAC with dedicated tests before surgical or invasive procedures is important for patient safety. It provides the best and most direct evidence to rule in (or to rule out) clinically relevant concentrations of residual drugs. Regulatory agencies should urgently approve their use in clinical practice. Hospital administrators should make them available, and clinical laboratories should set up the relative methods and make them available to clinicians.


Anticoagulation Direct oral anticoagulants Laboratory testing Surgery Invasive procedure Bleeding 


Compliance with ethical standards

Conflict of interest


Statement on human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent



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Copyright information

© SIMI 2018

Authors and Affiliations

  • Armando Tripodi
    • 1
    Email author
  • Francesco Marongiu
    • 2
  • Marco Moia
    • 1
  • Gualtiero Palareti
    • 3
  • Vittorio Pengo
    • 4
  • Daniela Poli
    • 5
  • Domenico Prisco
    • 6
  • Sophie Testa
    • 7
  • Maria Zanazzi
    • 8
  1. 1.Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital FoundationMilanItaly
  2. 2.Department of Medical Sciences and Public HealthUniversity of CagliariCagliariItaly
  3. 3.Arianna Anticoagulation Foundation-START Register SectionBolognaItaly
  4. 4.Cardiology Clinic, Department of Cardiac, Thoracic and Vascular SciencesUniversity of PaduaPaduaItaly
  5. 5.Thrombosis CentreCareggi University HospitalFlorenceItaly
  6. 6.Department of Experimental and Clinical MedicineUniversity of FlorenceFlorenceItaly
  7. 7.Department of Laboratory Medicine, Hemostasis and Thrombosis CentreDistrict HospitalCremonaItaly
  8. 8.Renal UnitAzienda Ospedaliero-Universitaria CareggiFlorenceItaly

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