TABLE 7

Management of anticoagulant agents in the peri-bronchoscopic period

Drug and route of administration	Mechanism of action	Indications	Half-life	When to withhold^#	When to restart h	Management of bleeding
Warfarin p.o.	Inhibits production of vitamin K-dependent clotting	VTE, AF and mechanical heart valves	40 h	5 days^¶	24	Vitamin K (p.o./i.v.), FFP, PCC, rFVIIa
Dabigatran p.o.	Reversible direct thrombin inhibitor	VTE and non-valvular AF	15 h	1–2 days⁺	24	Idarucizumab, dialysis, PCC, rFVIIa
Apixaban p.o.	Reversible selective factor Xa inhibitor	VTE and non-valvular AF	12 h	1–2 days⁺	24	Andexanet alfa^##, FFP and PCC, rFVIIa
Edoxaban p.o.	Selective factor Xa inhibitor	VTE after parenteral anticoagulant and non-valvular AF	12 h	1–2 days⁺	24	Andexanet alfa^##, FFP and PCC, rFVIIa
Rivaroxaban p.o.	Reversible selective factor Xa inhibitor	VTE and non-valvular AF	5–9 h	1–2 days⁺	24	Andexanet alfa^##, FFP and PCC, rFVIIa
UFH i.v./s.c.	Inactivates thrombin and activated factor X	VTE, ACS, mechanical heart valves, AF and bridging	60–90 min	4–6 h^§	12–24	Protamine sulfate
LMWH s.c.	Selectively binds to antithrombin	VTE, ACS, mechanical heart valves, AF and bridging	3–5 h	24 h⁺	24–72	Andexanet alfa^##, protamine sulfate, rFVIIa
Fondaparinux s.c.	Inhibits activated factor X indirectly	VTE, HIT and ACS	17 h	72 h⁺	24–72	rFVIIa
Argatroban i.v.	Reversible direct thrombin inhibitor	HIT, patients with HIT undergoing PCI	45 min	3 h^ƒ	12–24	rFVIIa
Desirudin i.v./s.c.	Reversible direct thrombin inhibitor	VTE prophylaxis after hip replacement	2–3 h	6–8 h⁺^,^§	12–24	rFVIIa
Bivalirudin i.v.	Reversible direct thrombin inhibitor	HIT, ACS undergoing PCI	25 min	2 h⁺	12–24	rFVIIa

UFH: unfractionated heparin; LMWH: low-molecular-weight heparin; VTE: venous thromboembolism; AF: atrial fibrillation; FFP: fresh frozen plasma; PCC: prothrombin complex concentrate; rFVIIa: recombinant activated factor VII; ACS: acute coronary syndrome; HIT: heparin-induced thrombocytopenia; PCI: percutaneous coronary intervention. ^#: consider withholding the medications for a longer period in patients prone to bleeding complications; ^¶: assess the international normalised ratio (INR) at least 7 days before bronchoscopy, and check the INR the day of the bronchoscopy; ⁺: in patients with renal disease, consider withholding these agents for a longer period prior to bronchoscopy; ^§: withhold these agents for a longer period prior to bronchoscopy after subcutaneous administration; ^ƒ: in patients with liver disease, consider withholding these agents for a longer period prior to bronchoscopy; ^##: not yet approved for use in the USA.