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DOAC Perioperative Management — RACP Adult Medicine MCQ

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HardClinical PharmacologyDOAC Perioperative ManagementRACP Adult Medicine

A 72-year-old man on apixaban for AF trips and falls, sustaining a hip fracture. He is scheduled for urgent hip arthroplasty. His last apixaban dose was 10 hours ago. Creatinine clearance is 45 mL/min. When is it safe to proceed with neuraxial (spinal) anaesthesia?

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Correct answer: E — After 72 hours from the last dose

For apixaban with CrCl 30–50 mL/min, the recommended time from last dose to neuraxial procedure is 48–72 hours (longer with renal impairment). With CrCl >50 mL/min, 24–48 hours is sufficient. This patient's CrCl of 45 mL/min warrants waiting ≥48 hours. If surgery cannot wait, general anaesthesia or peripheral nerve block is preferred. Specific reversal with andexanet alfa is an option for truly urgent cases. The 2025 DOAC guidelines provide detailed perioperative guidance.

Reference: ANZCA – 2024 – Neuraxial Anaesthesia and Anticoagulation; 2025 – DOAC Practical Guidelines