Is it necessary to discontinue Eliquis (apixaban) prior to cataract surgery?

From the Guidelines

In most cases, you do not need to stop taking Eliquis (apixaban) before cataract surgery, as cataract surgery is considered a low bleeding risk procedure, and the current practice generally allows patients to continue their anticoagulation therapy without interruption 1. However, this decision should always be made in consultation with both your ophthalmologist and the physician who prescribed your Eliquis. Some key points to consider include:

• The risk of bleeding during surgery
• The risk of thrombotic events from stopping Eliquis
• Individual patient factors such as bleeding risk, reason for taking Eliquis, and other medical conditions
• The pharmacokinetic-based approach to interrupting DOACs before elective surgery, which suggests withholding DOACs for 1 full day before a low-to-moderate-bleed-risk procedure 1. If discontinuation is recommended, typically Eliquis would be stopped 24-48 hours before surgery due to its relatively short half-life, and resumed within 24 hours after surgery if hemostasis is adequate. It is essential to inform your eye surgeon about all medications you're taking during your pre-operative assessment. According to the 2022 American College of Chest Physicians clinical practice guideline, for patients having a low-to-moderate-bleed-risk surgery/procedure, withholding DOACs for 1 full day before the procedure should result in a residual anticoagulant effect which is acceptable clinically for lower bleed risk procedures 1. In contrast, the 2018 European Heart Rhythm Association practical guide recommends not interrupting oral anticoagulation for most minor surgical procedures and those procedures where bleeding is easily controllable 1. Given the more recent and higher quality evidence from the 2022 guideline, it is recommended to follow a pharmacokinetic-based approach to interrupting DOACs before elective surgery 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.

The decision to stop Eliquis (apixaban) prior to cataract surgery depends on the perceived risk of bleeding.

• If cataract surgery is considered to have a low risk of bleeding, then apixaban should be discontinued at least 24 hours prior to the procedure.
• If cataract surgery is considered to have a moderate or high risk of unacceptable or clinically significant bleeding, then apixaban should be discontinued at least 48 hours prior to the procedure. Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established 2.

From the Research

Stopping Eliquis Prior to Cataract Surgery

• The decision to stop Eliquis (apixaban) prior to cataract surgery is a complex one, and the available evidence suggests that it may not be necessary to discontinue the medication in all cases 3, 4, 5.
• A study published in 2018 found that the risk of hemorrhage associated with cataract surgery is low if the international normalized ratio is in the therapeutic range, but noted that there were limited studies on direct oral anticoagulants like Eliquis 3.
• A more recent study from 2024 found that cataract surgery can be safely performed while continuing direct oral anticoagulation, including Eliquis, without an increased risk of intraoperative or postoperative bleeding 4.
• Another study from 2019 also found that phacoemulsification of cataract can be safely performed in patients taking Eliquis, with no intraocular bleeding or hemorrhagic complications observed during the 1-week follow-up 5.

Risks of Discontinuing Eliquis

• Discontinuing Eliquis prior to cataract surgery may increase the risk of thromboembolism, as noted in a study from 2018 3.
• A study from 2001 found that attempted cessation and recommencement of warfarin therapy may expose patients to a transient yet dangerous hypercoagulable state, and it is possible that similar risks may apply to Eliquis 6.

Recommendations

• The available evidence suggests that Eliquis can be continued during cataract surgery, but the decision to do so should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 4, 5.
• Further studies are needed to fully understand the risks and benefits of continuing or discontinuing Eliquis prior to cataract surgery 3, 7.