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 high-bleed-risk surgery and 24 hours before low-bleed-risk surgery, depending on kidney function, as stated in the most recent guideline 1.

Considerations for Holding Eliquis

When considering the management of Eliquis (apixaban) in patients with atrial fibrillation undergoing surgery, several factors must be taken into account, including the type of surgery, the patient's kidney function, and their individual bleeding risk.

• The American College of Chest Physicians clinical practice guideline suggests that the number of days of pre-operative Eliquis interruption before surgery depends on the bleed risk associated with the surgery and patient renal function 1.
• For patients with normal kidney function (CrCl ≥ 50 mL/min), holding Eliquis for 2 days before high-bleed-risk surgery and 1 day before low-to-moderate-bleed-risk surgery is recommended 1.
• In patients with impaired kidney function (CrCl < 50 mL/min), longer durations of Eliquis interruption may be necessary, with 4 days off recommended before high-bleed-risk surgery 1.

Importance of Individualized Management

It is crucial that the decision to hold Eliquis and the duration of interruption be individualized based on the patient's specific clinical circumstances, including their renal function and the type of surgery they are undergoing.

• The guideline emphasizes the importance of considering the unique management needs of patients receiving Eliquis, particularly those with impaired renal function 1.
• Healthcare providers should carefully assess each patient's risk factors and develop a personalized plan for managing Eliquis in the perioperative period.

Restarting Eliquis After Surgery

After surgery, Eliquis is typically restarted once adequate hemostasis is achieved, usually within 24-48 hours after the procedure for most surgeries.

• The timing of restarting Eliquis should be determined by the healthcare provider, taking into account the patient's individual clinical circumstances and the risk of bleeding versus the risk of stroke 1.

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 procedures with a moderate or high risk of bleeding, hold apixaban for at least 48 hours before surgery.
• 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 management of Eliquis (apixaban) in patients with atrial fibrillation undergoing surgery is crucial to minimize the risk of bleeding and thromboembolic events.
• According to the study 3, a standardized perioperative DOAC management strategy can be effective in reducing the risk of major bleeding and arterial thromboembolism.
• The study 3 suggests that apixaban can be omitted for 1 day before a low-bleeding-risk procedure and 2 days before a high-bleeding-risk procedure, and resumed 1 day after a low-bleeding-risk procedure and 2 to 3 days after a high-bleeding-risk procedure.

Bleeding Risk with Apixaban in Patients with Renal Impairment

• The risk of bleeding with apixaban in patients with renal impairment is a concern, but studies suggest that apixaban may be safer than warfarin in patients with renal failure 4, 5.
• The study 6 found that the risk of bleeding with apixaban in patients with mild renal impairment was significantly less compared to conventional anticoagulants.
• However, the study 7 found that worsening renal function was associated with a higher risk of subsequent cardiovascular events and bleeding, regardless of the anticoagulant used.

Clinical Considerations

• The decision to hold Eliquis (apixaban) for atrial fibrillation before surgery should be based on individual patient factors, including the type of surgery, bleeding risk, and renal function.
• The study 3 suggests that a perioperative management strategy without heparin bridging or coagulation function testing can be effective in reducing the risk of major bleeding and arterial thromboembolism.
• Clinicians should carefully evaluate the benefits and risks of holding Eliquis (apixaban) for atrial fibrillation before surgery, taking into account the patient's individual characteristics and the results of studies such as 6, 4, 7, 5, 3.