When should NOACs be ceased prior to surgery with a high bleeding risk?

In the context of managing patients on novel oral anticoagulants (NOACs) prior to surgery, the recommendation to cease NOACs three days before a procedure with a high bleeding risk is based on the pharmacokinetics of these medications. NOACs, such as dabigatran, rivaroxaban, and apixaban, have varying half-lives, but generally, they have a time to peak effect and a half-life that necessitates a careful approach to minimize the risk of perioperative bleeding.

By stopping the medication three days prior, there is sufficient time for the drug to clear from the system, reducing the anticoagulation effect and helping to ensure that the patient has a lower risk of excessive bleeding during and after the surgical procedure. This timeline is particularly important in surgeries that are known to pose a significant risk of bleeding, as having NOACs in the system can complicate hemostasis.

In contrast, ceasing the medications one or two days before surgery may not provide adequate clearance for some patients, especially those with renal impairment or those on higher doses. Ceasing NOACs a week in advance may be overly conservative, as it could increase the risk of thromboembolic events for patients who are