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Perioperative DOAC Management — EECC MCQ

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HardArrhythmia & ElectrophysiologyPerioperative DOAC ManagementEECC

A woman with metastatic breast cancer and symptomatic paroxysmal AF takes apixaban. Capecitabine is being replaced by enzalutamide for a second malignancy. Renal and hepatic function are normal. What is the key anticoagulation issue?

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Correct answer: B — Seek anticoagulation unaffected by enzalutamide induction

Enzalutamide is a potent enzyme inducer and can materially reduce exposure to factor-Xa inhibitors, risking thromboembolism. The response should be a pharmacist/haematology-informed review of the anticancer and anticoagulant choices, not an unvalidated dose adjustment or addition of aspirin. Active cancer alone does not prohibit a DOAC, but drug interactions, bleeding site, platelet count, renal function and expected treatment changes matter. The original question falsely attributed a simple switching rule to an unrelated trial.

Reference: 2024 ESC Guidelines for atrial fibrillation. https://www.escardio.org/guidelines/clinical-practice-guidelines/all-esc-practice-guidelines/atrial-fibrillation/