JAMA Netw Open

Most patients safely clear direct oral anticoagulants before surgery, with one possible exception

February 6, 2026

A new cohort study found that 7.6% of patients had elevated direct oral anticoagulant (DOAC) levels (≥30 ng/mL) at the time of elective surgery despite following standardized interruption protocols. Apixaban use, lower kidney function, and shorter interruption times were associated with higher preoperative DOAC concentrations. Notably, major bleeding events occurred only in patients with levels below 30 ng/mL, and no association was found between DOAC levels and surgical blood loss.

Clinical takeaway: Current interruption protocols appear safe for most patients, but clinicians may consider extra caution—or longer holds—for patients on apixaban or with impaired renal function undergoing high–bleeding-risk surgery.

Source:

Camilleri E, et al. (2026, February 4). JAMA Netw Open. Direct Oral Anticoagulant Levels at Time of Elective Surgery. https://pubmed.ncbi.nlm.nih.gov/41637074/