Perioperative Management of Direct Oral Anticoagulants (DOACs) in Elective Surgery Candidates: A Drug Utilization Evaluation (DUE) Study

Background: This study aimed to evaluate physicians' practice regarding perioperative Direct Oral Anticoagulants (DOACs) management in patients undergoing elective procedures and compare it to established institutional standard protocols and the most recent guidelines. Methods: Over seven months, a cross-sectional descriptive-analytical study was conducted at Imam Khomeini Hospital Complex, affiliated with Tehran University of Medical Sciences. Patients receiving DOACs and undergoing elective procedures/surgery were enrolled. Results: In total, 170 patients who underwent 200 procedures while taking DOACs were included, with a total mean age (SD) of 62.2 (16.5) years. DOAC therapy was primarily prescribed for atrial fibrillation (75%) and deep vein thrombosis (25%), with 97% taking Apixaban. Approximately 125 (62.5%) of the performed procedures were categorized as high risk for bleeding, among which only 16.8% adhered to preoperative management guidelines. The mean (SD) time to reintroduce DOACs after procedures was 57.7 (45.3) hours. Bridge therapy was used in 66% of cases before and 74% after procedures. Blood products were administered in 36 cases of high-risk procedures. The average overall perioperative management score calculated was 3.3, representing less than 50% of the maximum possible score of 7. In only 8.5% (N=17) of the procedures, the total pre- and postoperative management of DOACs was concordant with the guideline. Conclusion: The study showed poor perioperative adherence to international DOAC management guidelines. Expert collaboration is crucial for DOAC patients undergoing surgery. More research is needed to understand the reasons for low adherence.