What is the recommended duration to hold Eliquis (apixaban) for atrial fibrillation prior to surgery?

From the Guidelines

For atrial fibrillation patients taking Eliquis (apixaban), it is recommended to hold the medication for 48 hours before major surgery with high bleeding risk and 24 hours before minor procedures with low bleeding risk, depending on kidney function 1.

Key Considerations

• The timing of holding Eliquis is crucial to balance the risk of bleeding during surgery and the risk of stroke.
• Patients with normal kidney function should generally stop Eliquis at least 48 hours before major surgery with high bleeding risk.
• For minor procedures with low bleeding risk, stopping 24 hours beforehand is often sufficient.
• The specific timing should always be determined by the healthcare provider, taking into account the individual patient's stroke risk and bleeding risk during surgery.

Evidence-Based Recommendations

• A study published in Chest in 2022 recommends withholding DOACs, including apixaban, for 2 full days before a surgery/procedure for patients with high-bleed-risk surgery/procedure and normal kidney function 1.
• The same study suggests that for patients with low-to-moderate-bleed-risk surgery/procedure, withholding DOACs for 1 full day before the procedure may be sufficient.
• Another study published in Chest in 2022 provides guidance on the pre-operative management of antithrombotic therapy, including the use of apixaban, and recommends individualized management based on patient-specific factors, such as kidney function and bleeding risk 1.

Clinical Implications

• The management of Eliquis in the perioperative period requires careful consideration of the patient's individual risk factors and the type of surgery or procedure being performed.
• Healthcare providers should balance the risk of bleeding during surgery against the risk of stroke and make informed decisions about the timing of holding Eliquis.
• After surgery, Eliquis is typically restarted once adequate hemostasis is achieved, usually within 24-72 hours depending on the procedure's bleeding risk.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

Hold duration for Eliquis (apixaban) before surgery for atrial fibrillation:

• For procedures with a moderate or high risk of bleeding: hold apixaban for at least 48 hours before surgery 2.
• For procedures with a low risk of bleeding: hold apixaban for at least 24 hours before surgery 2.

From the Research

Perioperative Management of Eliquis (Apixaban) for Atrial Fibrillation

• The duration for holding Eliquis (apixaban) before surgery is not explicitly stated in the provided studies, but a study on perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant (DOAC) suggests omitting DOAC regimens for 1-2 days before a procedure based on bleeding risk and creatinine clearance levels 3.
• A standardized perioperative DOAC management strategy without heparin bridging or coagulation function testing was associated with low rates of major bleeding and arterial thromboembolism in patients with atrial fibrillation undergoing elective surgery or procedures 3.
• The decision to hold anticoagulation therapy, including Eliquis, should be individualized based on the patient's risk of thromboembolism and bleeding, as well as the type of surgery or procedure being performed 4, 5.

Bleeding and Thromboembolism Risks

• The risk of major bleeding and arterial thromboembolism in patients with atrial fibrillation undergoing surgery or procedures while on DOAC therapy, including Eliquis, is relatively low when a standardized perioperative management strategy is used 3.
• Studies have shown that bridging anticoagulation with low-molecular-weight heparin may not be necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure, and may actually increase the risk of major bleeding 4, 5.

Specific Guidance for Eliquis (Apixaban)

• A study on the efficacy and safety of apixaban in patients with atrial fibrillation and severe renal dysfunction found that apixaban may be a reasonable alternative to warfarin in these patients, but did not provide specific guidance on perioperative management 6.
• The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) cohort study found that a standardized perioperative DOAC management strategy, including apixaban, was associated with low rates of major bleeding and arterial thromboembolism in patients with atrial fibrillation undergoing elective surgery or procedures 3.