Management of patients with proximal femur fractures under DOACs

Abstract

Purpose In the past, preinjury direct oral anticoagulant (DOAC) intake has led to delays in time to surgery (TTS) in patients with proximal femur fractures and delays in surgery have been associated with impaired outcomes. Although healthcare institutions/federal committees have set rules for treatment within 24 h of injury, comprehensive guidelines for the perioperative management of these patients, in particular when on preinjury DOACs, are still lacking. This contribution aims to summarize the current evidence on the safe time window for surgery in patients with proximal femur fractures on preinjury DOACs and to outline therapeutic options if emergency DOAC reversal becomes necessary. Methods Narrative review based upon selective review of the pertinent literature. Results For the majority of patients with proximal femur fractures and on preinjury DOACs, early surgery appears safe as soon as medical clearance has been obtained. There may be an increase in the need for blood products but with data not yet conclusive. Work-up including assessment of remaining anticoagulant activity and potential reversal should be restricted to patients at risk for bleeding complications, in particular in the presence of renal/hepatic impairment. Methodology for rapid assessment of DOACs including quantitative/qualitative concentration levels is work in progress. In the case of bleeding, rapidly acting reversal agents are available. Conclusion Preinjury DOAC use should not routinely delay surgery in patients with proximal femur fractures.

Focus on the proximal femur

“…Thus, it was concluded that it is unnecessary to delay surgery for patients with PFF who are treated with platelet aggregation inhibitors. As no comprehensive guidelines for the perioperative management of patients under current treatment with direct oral anticoagulants (DOAC) are available, Marc Maegele summarizes the current evidence on the safe time window for surgery in patients in patients with PFF [ 6 ]. Furthermore, the author outlines the possible therapeutic options if emergency DOAC reversal becomes necessary.…”