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Head and Neck Surgery

Summary: Perioperative Management of Patients Taking Direct Oral Anticoagulants

19 Sep, 2024 | 21:12h | UTC

Direct oral anticoagulants (DOACs)—including apixaban, rivaroxaban, edoxaban, and dabigatran—are increasingly used for stroke prevention in atrial fibrillation and for treating venous thromboembolism. Effective perioperative management of DOACs is essential to minimize bleeding and thromboembolic risks during surgical and nonsurgical procedures. Below are practical recommendations focused on the perioperative management of patients taking DOACs, based on a recent JAMA review article.

Elective Surgical or Nonsurgical Procedures

Classify Bleeding Risk of Procedures:

  1. Minimal Risk:
    • Minor dental procedures (e.g., cleaning, extractions)
    • Minor dermatologic procedures (e.g., skin lesion removal)
    • Cataract surgery
  2. Low to Moderate Risk:
    • Endoscopic procedures without high-risk interventions
    • Cholecystectomy
    • Inguinal hernia repair
  3. High Risk:
    • Major surgery (e.g., cancer surgery, joint replacement)
    • Procedures involving neuraxial anesthesia
    • Endoscopic procedures with high-risk interventions (e.g., large polyp removal)

DOAC Management Strategies:

  1. Minimal Bleeding Risk Procedures:
    • Option 1: Continue DOACs without interruption.
    • Option 2: For added safety, withhold the morning dose on the day of the procedure (especially for twice-daily DOACs like apixaban and dabigatran).
  2. Low to Moderate Bleeding Risk Procedures:
    • Preoperative:
      • Discontinue DOACs 1 day before the procedure.
      • This allows approximately 2 half-lives for drug clearance.
    • Postoperative:
      • Resume DOACs 1 day after the procedure, ensuring adequate hemostasis.
  3. High Bleeding Risk Procedures:
    • Preoperative:
      • Discontinue DOACs 2 days before the procedure.
      • This allows approximately 4-5 half-lives for drug clearance.
    • Postoperative:
      • Resume DOACs 2-3 days after the procedure, based on bleeding risk and hemostasis.

Evidence Supporting These Strategies:

  • The PAUSE study demonstrated that standardized interruption protocols without heparin bridging result in low rates of:
    • Thromboembolism: 0.2%–0.4%
    • Major Bleeding: 1%–2%

Postoperative DOAC Resumption:

  • Assess surgical-site hemostasis before resuming DOACs.
  • Delay resumption if there is ongoing bleeding or concerns about hemostasis.
  • For high bleeding risk procedures, consider a longer delay (2–3 days).

Perioperative Heparin Bridging:

  • Not recommended for patients on DOACs.
  • Bridging increases bleeding risk without reducing thromboembolism.
  • DOACs have rapid offset and onset, making bridging unnecessary.

Special Considerations

Patients with Impaired Renal Function:

  • For CrCl 30–50 mL/min:
    • Dabigatran: Extend preoperative discontinuation by an additional day.
  • For CrCl <30 mL/min:
    • Dabigatran is contraindicated.
    • For other DOACs, consider extending discontinuation to 3–4 days before surgery.

Patients Undergoing Neuraxial Anesthesia:

  • Discontinue DOACs for 3 days (apixaban, edoxaban, rivaroxaban) or 4 days (dabigatran) before the procedure.
  • Minimizes risk of spinal or epidural hematoma.

Dental Procedures:

  • Generally safe to continue DOACs.
  • For added safety:
    • Omit or delay the dose on the day of the procedure.
    • Employ local hemostatic measures (e.g., tranexamic acid mouthwash).

Endoscopic Procedures:

  • Low-risk procedures (e.g., diagnostic endoscopy without biopsy):
    • Follow standard DOAC interruption for low to moderate bleeding risk.
  • High-risk procedures (e.g., polypectomy of large polyps):
    • Extend DOAC discontinuation by an additional day pre- and post-procedure.

Patients Unable to Resume Oral Medications Postoperatively:

  • Use prophylactic low-molecular-weight heparin (LMWH) until oral intake is possible.
  • Avoid therapeutic-dose LMWH due to bleeding risk.

Emergent, Urgent, or Semiurgent Procedures

Risks:

  • Higher bleeding risk: Up to 23%
  • Thromboembolism risk: Up to 11%

Management Strategies:

  1. Assess Time Since Last DOAC Dose:
    • If within 48 hours, consider that significant anticoagulant effect may persist.
  2. Laboratory Testing (if available):
    • DOAC Level Testing:
      • ≥50 ng/mL: Consider using reversal agents.
      • <50 ng/mL: May proceed without reversal agents.
  3. Use of Reversal Agents:
    • For Dabigatran:
      • Idarucizumab (5 g IV)
    • For Factor Xa Inhibitors (apixaban, rivaroxaban, edoxaban):
      • Andexanet alfa (dosing based on last dose timing and amount)
      • Prothrombin Complex Concentrates (PCCs): If andexanet alfa is unavailable or contraindicated.
  4. Proceeding Without Testing:
    • If testing is unavailable and last DOAC dose was within 48 hours, consider reversal agents.
    • If >48 hours since last dose, may proceed without reversal.

Considerations:

  • Reversal agents are expensive and may carry thrombotic risks.
  • Use should be judicious, weighing risks and benefits.
  • Consult hematology or thrombosis experts when possible.

Key Takeaways

  • Elective Procedures:
    • Utilize standardized protocols based on procedural bleeding risk.
    • Routine preoperative DOAC level testing is unnecessary.
    • Avoid heparin bridging.
  • Emergent/Urgent Procedures:
    • Reversal agents may be appropriate when significant DOAC levels are present.
    • Decision to use reversal agents should consider bleeding risk, time since last dose, and availability of DOAC level testing.
  • Patient Communication:
    • Ensure patients understand the plan for DOAC interruption and resumption.
    • Provide clear instructions regarding timing and dosing.
  • Interdisciplinary Coordination:
    • Collaborate with surgical teams, anesthesiologists, and pharmacists.
    • Use electronic medical records and clinical decision support tools to enhance communication.

Conclusion

By applying standardized perioperative management protocols, clinicians can effectively balance the risks of bleeding and thromboembolism in patients taking DOACs who require surgical or nonsurgical procedures. These strategies simplify decision-making, avoid unnecessary interventions like heparin bridging, and promote patient safety.

Reference: Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA. 2024;332(10):825–834. doi:10.1001/jama.2024.12708

 

Cohort Study: GLP1 receptor agonist use not associated with significant increase in thyroid cancer risk – The BMJ

25 May, 2024 | 19:51h | UTC

A large Scandinavian cohort study investigated the association between glucagon-like peptide 1 (GLP1) receptor agonist use and thyroid cancer risk in Denmark, Norway, and Sweden from 2007 to 2021. The study compared 145,410 patients treated with GLP1 receptor agonists to 291,667 patients treated with dipeptidyl peptidase 4 (DPP4) inhibitors and included an additional analysis with sodium-glucose cotransporter 2 (SGLT2) inhibitors. Results showed no significant increase in thyroid cancer risk among GLP1 users over a mean follow-up of 3.9 years, with a hazard ratio of 0.93 (95% CI, 0.66 to 1.31) compared to DPP4 inhibitor users. The study utilized nationwide cancer registers and employed an active-comparator, new user design to minimize confounding, using Cox regression models adjusted by propensity score weighting. The findings suggest that while small risk increases cannot be definitively ruled out, the use of GLP1 receptor agonists does not substantially elevate thyroid cancer risk.

 

Reference (link to free full-text):

Björn Pasternak et al. (2024). Glucagon-like peptide 1 receptor agonist use and risk of thyroid cancer: Scandinavian cohort study. BMJ, 385. DOI: https://doi.org/10.1136/bmj-2023-078225

 

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7 Aug, 2023 | 14:40h | UTC

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See also: Visual Abstract

 

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27 Jul, 2023 | 12:58h | UTC

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25 Jul, 2023 | 13:52h | UTC

Dysphagia-optimised intensity-modulated radiotherapy versus standard intensity-modulated radiotherapy in patients with head and neck cancer (DARS): a phase 3, multicentre, randomised, controlled trial – The Lancet Oncology

Commentaries:

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Radiation approach improves swallowing in head, neck cancer – MDedge

 

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17 Jul, 2023 | 13:25h | UTC

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Invited Commentary: Circulating Human Papillomavirus Tumor DNA—Ready for Prime Time? –  – JAMA Otolaryngology–Head & Neck Surgery (free for a limited period)

 

2023 ETA clinical practice guidelines for thyroid nodule management

12 Jul, 2023 | 13:48h | UTC

2023 European Thyroid Association clinical practice guidelines for thyroid nodule management – European Thyroid Journal

 

The 2023 Bethesda System for reporting thyroid cytopathology

12 Jul, 2023 | 13:46h | UTC

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5 Jun, 2023 | 13:29h | UTC

Role of chemotherapy in patients with nasopharynx carcinoma treated with radiotherapy (MAC-NPC): an updated individual patient data network meta-analysis – The Lancet Oncology (free for a limited period)

 

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18 May, 2023 | 13:34h | UTC

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5 May, 2023 | 14:55h | UTC

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Study shows that parathyroidectomy in adults with primary hyperparathyroidism probably has no effect on kidney function

21 Apr, 2023 | 12:57h | UTC

Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism – Annals of Internal Medicine (link to abstract – $ for full-text)

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30 Mar, 2023 | 14:19h | UTC

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Feasibility and efficacy of microwave ablation in the treatment of papillary thyroid microcarcinoma: a prospective cohort study

14 Mar, 2023 | 13:30h | UTC

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14 Mar, 2023 | 13:22h | UTC

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RCT | Perioperative vs. postoperative calcium and vitamin D supplementation to prevent symptomatic hypocalcemia after total thyroidectomy

6 Mar, 2023 | 14:09h | UTC

Summary:

This study aimed to compare the efficacy of perioperative vs. postoperative calcium and vitamin D supplementation in reducing symptomatic hypocalcemia in patients who underwent thyroidectomy.

In a randomized placebo-controlled trial involving 134 patients, one group received calcium carbonate and alfacalcidol both 3 days before surgery and for 14 days after surgery, while the other group received the same treatment only after surgery.

Results showed that the perioperative group had significantly lower rates of symptomatic and biochemical hypocalcemia compared to the postoperative group. Patients who underwent central neck dissection were at increased risk of symptomatic hypocalcemia in this study, so perioperative supplementation could be more beneficial for these patients.

 

Article: Perioperative versus postoperative calcium and vitamin D supplementation to prevent symptomatic hypocalcemia after total thyroidectomy: a randomized placebo controlled trial – International Journal of Surgery

 

M-A | Complications of percutaneous tracheostomy in critically ill adults with obesity

13 Feb, 2023 | 12:37h | UTC

Complication Rate of Percutaneous Dilatational Tracheostomy in Critically Ill Adults With Obesity: A Systematic Review and Meta-analysis – JAMA Otolaryngology-Head & Neck Surgery (free for a limited period)

 

RCT | Medial retropharyngeal nodal region sparing radiotherapy vs. standard radiotherapy in patients with nasopharyngeal carcinoma

7 Feb, 2023 | 14:09h | UTC

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Salivary gland cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

27 Jan, 2023 | 12:16h | UTC

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NICE Guideline | Thyroid cancer: assessment and management

11 Jan, 2023 | 14:34h | UTC

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MRI of acute neck infections: evidence summary and pictorial review

10 Jan, 2023 | 14:33h | UTC

MRI of acute neck infections: evidence summary and pictorial review – Insights into Imaging

 

Cohort Study | Tobacco use and incidence of adverse oral health outcomes.

12 Dec, 2022 | 12:30h | UTC

Tobacco Use and Incidence of Adverse Oral Health Outcomes Among US Adults in the Population Assessment of Tobacco and Health Study – JAMA Network Open

Commentary: Expert reaction to study looking at smoking, vaping and oral health – Science Media Centre

 

Cohort Study | Lobectomy vs. total thyroidectomy for intermediate-risk papillary thyroid carcinoma with lymph node metastasis.

6 Dec, 2022 | 13:41h | UTC

Comparison of Lobectomy vs Total Thyroidectomy for Intermediate-Risk Papillary Thyroid Carcinoma With Lymph Node Metastasis – JAMA Surgery (free for a limited period)

Invited Commentary: Is Lobectomy as Effective as Total Thyroidectomy in Treating Patients With Intermediate-Risk Papillary Thyroid Carcinoma With Lateral Lymph Node Metastasis? – JAMA Surgery (free for a limited period)

 

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Case–control study | GLP-1 receptor agonists linked to increased risk of thyroid cancer.

25 Nov, 2022 | 12:42h | UTC

GLP-1 Receptor Agonists and the Risk of Thyroid Cancer – Diabetes Care (link to abstract – $ for full-text)

Commentary: GLP-1 receptor agonists associated with thyroid cancer – ACP Internist

 

M-A | Efficacy of laryngeal mask airway against postoperative pharyngolaryngeal complications following thyroid surgery.

1 Nov, 2022 | 12:05h | UTC

Efficacy of laryngeal mask airway against postoperative pharyngolaryngeal complications following thyroid surgery: a systematic review and meta-analysis of randomized controlled studies – Scientific Reports

 

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