When can Eliquis (apixaban) be restarted in a patient who underwent debridement of Fournier's gangrene and is currently on prophylactic heparin?

From the Guidelines

Eliquis (apixaban) can typically be restarted 24-48 hours after surgery for a patient with Fournier's gangrene, assuming adequate hemostasis has been achieved and the surgical team confirms there is minimal bleeding risk. I recommend waiting at least 24 hours post-debridement, with 48 hours being preferable for higher bleeding risk procedures, as suggested by the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1. Continue the prophylactic heparin until 2 hours before restarting the Eliquis at the patient's previous dosage. Before restarting, assess the wound for any signs of active bleeding, oozing, or hematoma formation. Also consider the patient's renal function, as impaired kidney function may require dose adjustment, according to the 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation 1. The timing balances the risk of thrombotic events against bleeding complications. Fournier's gangrene debridement creates raw surfaces with potential for bleeding, but delaying anticoagulation too long increases thrombotic risk. Discuss the specific timing with the surgical team, as they can best assess the local bleeding risk based on the extent of debridement performed.

Some key considerations when deciding to restart Eliquis include:

• The patient's individual risk of thromboembolism and bleeding
• The type of surgery performed and the associated bleeding risk
• The patient's renal function and potential need for dose adjustment
• The presence of any signs of active bleeding, oozing, or hematoma formation

It is essential to weigh these factors and consider the latest guidelines, such as those from the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1, to make an informed decision about when to restart Eliquis in a patient with Fournier's gangrene. Additionally, the 2012 study on how to treat anticoagulated patients undergoing an elective procedure or surgery provides a suggested management approach for postoperative resumption of new oral anticoagulants, including apixaban 1. However, the most recent and highest quality study, the 2020 ACC expert consensus decision pathway, should be prioritized when making a decision about restarting Eliquis 1.

From the FDA Drug Label

Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established. The patient can restart Eliquis (apixaban) as soon as adequate hemostasis has been established after the surgical procedure.

• The timing of restarting apixaban depends on the achievement of adequate hemostasis, not on a specific time frame after the procedure 2.

From the Research

Restarting Eliquis After Surgery

The decision to restart Eliquis (apixaban) after surgery, particularly in a patient who has undergone debridement of Fourier gangrene and is currently on prophylactic heparin, should be based on the patient's individual risk factors for thromboembolism and bleeding.

Considerations for Restarting Eliquis

• The patient's renal function is a crucial factor, as apixaban is renally cleared and its use in patients with severe renal impairment may require careful consideration 3, 4, 5.
• Studies have shown that apixaban can be safely used in patients with end-stage renal disease (ESRD) and may be associated with a lower risk of bleeding compared to warfarin 3, 4, 5.
• However, the provided studies do not directly address the timing of restarting Eliquis after surgery, and the decision should be made on a case-by-case basis, taking into account the patient's overall clinical condition and risk factors.

Bleeding Risk Considerations

• The risk of bleeding is a significant concern when restarting anticoagulation therapy after surgery, and the use of prophylactic heparin may affect this risk.
• Studies have shown that apixaban may be associated with a lower risk of bleeding compared to warfarin in patients with ESRD, but the risk of bleeding is still present and should be carefully monitored 3, 4, 5.

Clinical Decision-Making

• The decision to restart Eliquis should be made in consultation with the patient's healthcare team, taking into account the patient's individual risk factors and clinical condition.
• The provided studies do not offer direct guidance on the timing of restarting Eliquis after surgery, and the decision should be based on the patient's overall clinical picture and the healthcare team's professional judgment.