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Edward Lee Carter: Why Periprocedural DOAC Guidance Needs a Common Output Standard

Edward Lee Carter/LinkedIn

Sep 29, 2026, 16:18

Edward Lee Carter: Why Periprocedural DOAC Guidance Needs a Common Output Standard

Edward Lee Carter, Clinical Pharmacist Practitioner at U.S. Department of Veterans Affairs, shared on LinkedIn about his recent article published in Annals of Pharmacotherapy, adding:

“Five tools. One patient. Same plan before surgery. Different answers after.

My Letter to the Editor is now published in Annals of Pharmacotherapy.

Periprocedural DOAC management is usually framed as a pharmacokinetic problem.

In practice, it’s also a translation problem. ‘Hold 2 days,’ ‘skip 4 doses,’ and ‘stop at least 48 hours’ all have to become one unambiguous medication calendar, at the exact moment when both clot and bleeding risk are elevated.

I ran one hypothetical patient through 5 publicly available resources: IPRO MAPPP, ACC ManageAnticoag, Thrombosis Canada, Anticoagulation Forum guidance, and the MAQI2 Toolkit.

The patient: 79 years old, nonvalvular AF, apixaban 5 mg twice daily, CrCl 55, CHA2DS2-VASc 7, scheduled for total knee arthroplasty.

Before surgery, all 5 tools agreed:

Last dose on day -3
Hold on days -2 and -1, and on the day of surgery
No therapeutic heparin bridging
Resume at 48 to 72 hours if hemostasis is adequate

After surgery, they diverged.

Some surfaced reduced-dose DOAC or prophylactic LMWH before therapeutic resumption.

Others went straight to therapeutic apixaban at 48 to 72 hours.

That matters because:

VTE prophylaxis is not therapeutic AF anticoagulation.
CHA2DS2-VASc does not estimate postoperative VTE risk.

The letter proposes a minimum common output standard.

It doesn’t require identical algorithms, only explicit outputs: the indication, the final dose with date and time, every omitted dose, whether parenteral therapy is bridging or prophylaxis, the conditional restart window, the hemostatic checkpoint, the accountable clinician, and the evidence source, version, and review date.

Decision support should standardize the workflow, not merely shorten the recommendation.”

Title: Five Tools, One Patient: Toward a Common Output Standard for Periprocedural Anticoagulation Decision Support

Authors: Edward L. Carter

Edward Lee Carter