TABLE 2

Half-life and reversal of selected antithrombotic agents

AgentHalf-life with normal renal functionReversal prior to elective procedure Reversal prior to urgent procedure
Oral antiplatelet agents
 Cyclo-oxygenase inhibitorAspirin20 minNAPlatelet transfusion
 Irreversible P2Y12 ADP receptor inhibitorClopidogrel6–8 hWithhold drug 5–10 days prior to procedurePlatelet transfusion, desmopressin in severe cases
 Irreversible P2Y12 ADP receptor inhibitorPrasugrel2–15 hWithhold drug 5–10 days prior to procedurePlatelet transfusion, desmopressin in severe cases
 Irreversible P2Y12 ADP receptor inhibitorTiclopidine12 hWithhold drug 10–14 days prior to procedurePlatelet transfusion, desmopressin in severe cases
 Reversible P2Y12 ADP receptor inhibitorTicagrelor7 hWithhold drug 5–10 days prior to procedurePlatelet transfusion, desmopressin in severe cases
Oral anticoagulant agents
 Vitamin K antagonistWarfarin20–60 hWithhold drug 5 days prior to procedure, monitor INRi.v. vitamin K, four-factor PCC, three-factor PCC or activated PCC
 Direct factor Xa inhibitorRivaroxaban5 hWithhold drug ≥24 h prior to procedureConsider three- or four-factor PCC or activated PCC
 Direct factor Xa inhibitorEdoxaban10–14 hWithhold drug ≥24 h prior to procedureConsider three- or four-factor PCC or activated PCC
 Direct factor Xa inhibitorApixaban12 hWithhold drug ≥48 h prior to procedures with high bleed risk; withhold drug ≥24 h prior to procedures with low bleed riskConsider three- or four-factor PCC or activated PCC
 Direct thrombin inhibitorDabigatran12–17 hWithhold drug 1–2 days prior to procedure (CrCl ≥50 mL·min−1); withhold drug 3–5 days prior to procedure (CrCl <50 mL·min−1); longer for patients undergoing spinal puncture or major surgeryIdarucizumab
Parenteral anticoagulant agents
 Anti-Xa, antithrombin III inhibitorUFH60–90 minWithhold drug 4–6 h prior to procedureProtamine sulfate
 LMWHEnoxaparin4.5 hWithhold drug 24 h prior to procedureProtamine sulfate
 LMWHDalteparin2.5 hWithhold drug 24 h prior to procedureProtamine sulfate

ADP: adenosine diphosphate; LMWH: low molecular weight heparin; NA: not applicable; INR: international normalised ratio; PCC: prothrombin complex concentrate; CrCl: creatinine clearance; UFH: unfractionated heparin.