Bleeding is relatively common risk of any surgery and especially surgeries like hip or knee arthroplasty. A patient on blood thinners could bleed excessively during surgery; therefore, it is important that you stop your blood thinners prior to your surgery.
Most low-risk, daily maintenance medications may be continued throughout the perioperative period and pose little risk if abruptly discontinued. However, those with cardiac comorbidities, history of venous thromboembolism, diabetes mellitus, and/or autoimmune disorders warrant a closer review of their medication profiles and careful management to mitigate perioperative risks. Every patient should discuss their medication with their surgeon and if possible with the prescribing physician. There should be open communication between the surgeon and the cardiologist. Cardio-vascular disease is very common in the United States. Surgeons must stay up to date on perioperative management of antithrombotic medications in order to optimize their patients.
The following are guidelines reviewed and published by the American Academy of Orthopaedic Surgeons (AAOS) for some of the most common anticoagulant medications.
Antiplatelet Agents: Aspirin, Clopidogrel (PLAVIX), Prasugrel (EFFIENT), Ticagrelor (BRILINTA): These agents last the lifetime of the platelet since their effects are irreversible. These agents should be stopped 5 days prior to elective hip or knee surgery. The exception is aspirin, which at low doses (75-100mg daily) may be continued through the perioperative period.
Coagulation Cascade Inhibitors: Apixaban (ELIQUIS), Rivaroxaban (XARELTO), Dabigatran (PRADAXA): These agents inhibit the coagulation cascade and may be discontinued 2 days prior to elective arthroplasty. While their half-lives are longer than those of antiplatelet agents, their reversible nature allows a later discontinuation prior to surgery.
Vitamin K Antagonists: Warfarin (COUMADIN): Warfarin is commonly used in those with atrial fibrillation; a powerful anticoagulant, its main disadvantage is the need for periodic monitoring of a patient’s international normalized ratio (INR). It inhibits the vitamin K-mediated carboxylation of clotting factors and must be discontinued at varying time points prior to elective arthroplasty depending on the INR: either 3 days (if INR <2.0), 5 days (if INR 2-3), or 6 days (if INR 3-4.5).
There are certain medical conditions where warfarin cannot be stopped and a certain kind of blood thinner has to be given. In such circumstances, patients must be bridged by a blood thinner with a short half-life, such as the low molecular weight heparin (LMWH). There should be a clear blood thinner bridging plan developed by the cardiologist or your surgeon.
1. Barlow, Brian T., Matthew T. Hannon, and Jacob E. Waldron. "Preoperative management of antithrombotics in arthroplasty." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 27.23 (2019): 878-886.
2. Cleveland Clinic. “Cleveland Clinic Anticoagulation Management Program (C-CAMP).” Cleveland Clinic Journal (2012)
3. Guyatt, Gordon H., et al. "Executive summary: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines." Chest 141.2 Suppl (2012): 7S.