How many days to hold Eliquis (apixaban) prior to surgery?

From the Guidelines

Eliquis should be held for at least 48 hours before high-bleed-risk surgery and at least 24 hours before low-to-moderate-bleed-risk surgery, with no Eliquis taken on the day of surgery, as recommended by the most recent guidelines 1. The timing for holding Eliquis (apixaban) before surgery depends on the bleeding risk of the procedure.

• For procedures with low bleeding risk, Eliquis should be stopped at least 24 hours before surgery, which corresponds to approximately three Eliquis half-lives.
• For procedures with high bleeding risk, Eliquis should be stopped at least 48 hours before surgery, which corresponds to approximately four to five Eliquis half-lives. Patients with reduced kidney function (creatinine clearance less than 50 mL/min) may need to stop Eliquis earlier, as the drug's clearance is affected by renal function 1. This timing allows the anticoagulant effect to decrease sufficiently to reduce the risk of surgical bleeding. The recommendation accounts for the half-life of Eliquis, which is approximately 12 hours in patients with normal kidney function 1. After surgery, Eliquis can typically be resumed 24-48 hours later once adequate hemostasis is achieved, but this should be determined by your healthcare provider based on your specific situation and bleeding risk 1. Always consult with your surgeon and the doctor who prescribed Eliquis before making any changes to your medication schedule.

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 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 recommended time to hold Eliquis (apixaban) prior to surgery is at least 48 hours for procedures with a moderate or high risk of bleeding, and at least 24 hours for procedures with a low risk of bleeding. 2

From the Research

Apixaban Discontinuation Prior to Surgery

• The study 3 suggests that apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure.
• The median time between the self-reported last dose and presurgery blood sampling was 76 hours for those who achieved concentrations ≤ 30 ng/mL.
• It is recommended to hold apixaban for at least 48 hours prior to surgery, but the exact duration may vary depending on individual patient factors and the type of surgery.

Comparison with Other Anticoagulants

• Studies 4, 5, 6, and 7 compared apixaban with low-molecular-weight heparin (LMWH) or warfarin in various clinical settings, including venous thromboembolism treatment and prevention.
• These studies demonstrated that apixaban is effective and safe in preventing venous thromboembolism, with a lower risk of bleeding compared to LMWH or warfarin.
• However, these studies do not provide specific guidance on the duration of apixaban discontinuation prior to surgery.

Clinical Implications

• The decision to hold apixaban prior to surgery should be made on a case-by-case basis, taking into account the individual patient's risk factors and the type of surgery.
• Clinicians should consider the results of the study 3 and other relevant studies when making decisions about apixaban discontinuation prior to surgery.
• Further research is needed to determine the optimal duration of apixaban discontinuation prior to surgery in different clinical settings.