PERIOPERATIVE ANTICOAGULATION MANAGEMENT: A HEMATOLOGIST–CARDIOLOGIST PERSPECTIVE ON RISK STRATIFICATION AND THERAPEUTIC DRUG MONITORING

Emmanuel Ifeanyi Obeagu; Olga Goryacheva

doi:10.22270/ujpr.v11i5.1673

Emmanuel Ifeanyi Obeagu Division of Haematology, Department of Biomedical and Laboratory Science, Africa University, Mutare, Zimbabwe. Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Department of Internal Diseases, Perm State Medical University named after Academician E.A. Wagner, Perm, Russia.
Olga Goryacheva Department of Internal Diseases, Perm State Medical University named after Academician E.A. Wagner, Perm, Russia.

10.22270/ujpr.v11i5.1673

Keywords:

anticoagulants, drug safety, perioperative management, therapeutic drug monitoring, high risk populations

Abstract

Direct oral anticoagulants (DOACs) are widely used for thromboprophylaxis in atrial fibrillation and venous thromboembolism. Their marketing emphasizes predictable pharmacokinetics and no need for routine monitoring. However, the perioperative period exposes critical limitations of this paradigm, especially in high‑risk populations excluded from landmark trials. This narrative review integrates hematology and cardiology perspectives. We critically examined real‑world evidence on perioperative DOAC management, focusing on patients with extreme body weight, renal or hepatic impairment, active malignancy, thrombocytopenia, bariatric surgery, and drug–drug interactions. Guideline recommendations and commercial influences were analyzed. Routine therapeutic drug monitoring (TDM) is unnecessary for low‑risk elective procedures in standard patients. However, selective TDM is essential in high‑risk populations where DOAC pharmacokinetics are unpredictable. We identified specific indications for TDM (extreme body weight, CrCl<50 mL/min, Child‑Pugh B cirrhosis, bariatric surgery, interacting drugs) and provided practical algorithms for elective, urgent and emergency surgery. Low‑Molecular‑Weight heparin (LMWH) is preferred when DOAC pharmacokinetics are unpredictable, including malabsorption syndromes, severe thrombocytopenia, and advanced liver disease. Marketing influences have perpetuated the “no monitoring” dogma despite accumulating evidence of harm in vulnerable subgroups. A one‑size‑fits‑all approach to perioperative anticoagulation is unsafe in complex patients. Selective TDM improves safety in high‑risk scenarios. LMWH remains a preferred alternative when DOAC pharmacokinetics are unpredictable. Clinicians should recognise marketing influences and adopt evidence‑based, individualised strategies.