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 bleeding risk is acceptable. I recommend waiting at least 24 hours post-debridement, with 48 hours being preferable for this type of procedure due to the highly vascular nature of the perineal region. According to the most recent guidelines 1, the decision to restart anticoagulation should be based on the patient's individual risk factors, including the risk of bleeding and thromboembolism.

Some key considerations before restarting Eliquis include:

• Assessing for active bleeding at the surgical site
• Checking hemoglobin levels for stability
• Ensuring the patient has normal renal function, as impaired kidneys can increase bleeding risk with Eliquis
• Consulting with the surgical team to evaluate the local wound conditions

The 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1 suggests that anticoagulation can likely be restarted 24 hours after a procedure with low postprocedural bleeding risk, and 48 to 72 hours after a procedure with higher bleeding risk. However, the specific timing of restarting Eliquis should be individualized based on the patient's clinical situation.

It's also important to note that Eliquis has a relatively quick onset of action (3-4 hours to peak effect), so the transition from prophylactic heparin should be straightforward without requiring overlap therapy. Continue prophylactic heparin until 2 hours before restarting Eliquis at the patient's previous dosage.

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 depends on various factors, including the type of surgery, patient's renal function, and risk of bleeding or thrombosis.
• According to a study published in 2021 3, apixaban can be an effective alternative to enoxaparin for thromboprophylaxis after total knee replacement surgery, with no significant difference in wound complications or deep venous thrombosis incidence.
• However, another study from 2015 4 suggests that the risk of bleeding with apixaban in patients with mild renal impairment is lower compared to conventional anticoagulants, while the risk is similar in patients with moderate to severe renal impairment.
• A 2025 study 5 found no difference in safety or effectiveness between apixaban and warfarin for the treatment of venous thromboembolism in patients with severe renal impairment.

Considerations for Restarting Eliquis

• The patient's current prophylactic heparin treatment should be taken into account when deciding to restart Eliquis.
• A study from 2012 6 found that restricting enoxaparin use in patients with severe renal impairment and using unfractionated heparin instead can decrease the risk of bleeding.
• The patient's renal function and creatinine clearance rate should be assessed before restarting Eliquis, as apixaban is primarily eliminated through the kidneys.
• Close monitoring of the patient's bleeding risk and thrombosis risk is necessary when restarting Eliquis after surgery.

Timing of Restarting Eliquis

• There is no specific guidance on the exact timing of restarting Eliquis after surgery, and the decision should be made on a case-by-case basis.
• The 2021 study 3 initiated apixaban 12 hours after surgery, while the 2015 study 4 did not specify the exact timing of apixaban initiation.
• The patient's individual risk factors, such as renal function, age, and comorbidities, should be considered when determining the optimal timing for restarting Eliquis.