{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T20:13:10Z","timestamp":1782504790592,"version":"3.54.5"},"reference-count":31,"publisher":"American Medical Association (AMA)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Before elective surgery, direct oral anticoagulants (DOACs) are discontinued following a standardized protocol. However, this could result in insufficient lowering of DOAC levels that could increase bleeding risk.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To estimate the proportion of patients with elevated DOAC levels at the time of elective surgery, evaluate factors associated with DOAC levels, and examine associated blood loss.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This cohort study (DOAC Level Prior to Incision [DALI]) assessed adult patients prescribed a DOAC (apixaban, dabigatran, or rivaroxaban) for any indication and at any dose, undergoing an elective procedure requiring DOAC interruption between May 27, 2018, and February 25, 2024, at 2 Dutch hospitals.<\/jats:p>\n <\/jats:sec>\n \n Exposure<\/jats:title>\n Standardized interruption protocol (1 day before moderate- and 2 days before high bleeding-risk procedures) with interruption adjustments for the patient\u2019s kidney function.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Blood was drawn immediately before surgery to determine DOAC levels (by liquid chromatography\u2013mass spectrometry). Proportions of preoperative DOAC levels of 30 ng\/mL or higher and their 95% CIs were estimated, stratified by DOAC type and surgical bleeding risk. Factors associated with DOAC levels were identified through multivariable linear regression. Surgical blood loss and 30-day postoperative complications were described according to DOAC concentrations.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The study was terminated after including 257 patients (100 receiving apixaban, 100 receiving rivaroxaban, and 57 receiving dabigatran due to the slow inclusion rate of those receiving dabigatran; median [IQR] age, 72 [66-78] years; 173 male [67%]); 212 patients (82%) underwent a high bleeding-risk operation. Preprocedural DOAC levels were 30 ng\/mL or higher in 7.6% (95% CI, 4.9%-11.6%) of patients. Dabigatran and rivaroxaban had similar proportions, whereas 13.1% (95% CI, 7.8%-21.2%) of patients treated with apixaban had levels of 30 ng\/mL or higher. Treatment with apixaban, decreased kidney function, and a shorter interruption time were associated with higher levels. Surgical blood loss (median [range], 0 [0-4250] mL) was not associated with DOAC levels. Twelve patients (4.7%; 95% CI, 2.7%-8.0%), who all had DOAC levels less than 30 ng\/mL, experienced major bleeding.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this cohort study, most patients following the current protocol had DOAC levels less than 30 ng\/mL, although the proportion of patients with elevated levels was higher for apixaban. Preoperative DOAC levels were not associated with blood loss during surgery.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.55875","type":"journal-article","created":{"date-parts":[[2026,2,4]],"date-time":"2026-02-04T16:30:33Z","timestamp":1770222633000},"page":"e2555875","source":"Crossref","is-referenced-by-count":3,"title":["Direct Oral Anticoagulant Levels at Time of Elective Surgery"],"prefix":"10.1001","volume":"9","author":[{"given":"Eleonora","family":"Camilleri","sequence":"first","affiliation":[{"name":"Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Payam","family":"Shahbabai","sequence":"additional","affiliation":[{"name":"Department of Hospital Pharmacy, Haga Teaching Hospital, The Hague, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mandana","family":"Rad","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Haga Hospital Juliana Children\u2019s Hospital, Den Haag, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charlotte A.","family":"Huijzer","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Menno V.","family":"Huisman","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eveline L. 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Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands"},{"name":"Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nienke","family":"van Rein","sequence":"additional","affiliation":[{"name":"Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands"},{"name":"Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,2,4]]},"reference":[{"issue":"11","key":"zoi251485r1","doi-asserted-by":"publisher","first-page":"1966","DOI":"10.1111\/jth.14598","article-title":"Scientific and Standardization Committee Communication: guidance document on the periprocedural management of patients on chronic oral 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