Should Eliquis (apixaban) be held prior to hip replacement surgery?

From the Guidelines

Eliquis (apixaban) should be held at least 48 hours prior to hip replacement surgery for patients with normal or mild renal impairment, and at least 72 hours for those with moderate renal impairment, as suggested by the management approach outlined in the study published in Blood 1. When considering the management of anticoagulated patients undergoing elective procedures or surgery, it's crucial to balance the risk of bleeding against the risk of thromboembolic events.

• The study provides a suggested management approach for preoperative interruption of new oral anticoagulants, including apixaban, based on patient renal function and bleeding risk.
• For apixaban, the study suggests holding the medication 2 days before surgery (skipping 2 doses) for patients with normal or mild renal impairment, and 3 days before surgery (skipping 4 doses) for those with moderate renal impairment.
• The decision to hold Eliquis prior to surgery should be individualized, taking into account the patient's specific clinical circumstances, including their renal function, bleeding risk, and overall health status.
• After surgery, the timing of restarting Eliquis will depend on various factors, including the patient's renal function, bleeding risk, and the surgeon's or anesthesiologist's assessment of the patient's overall condition.
• It's essential for patients to follow the specific instructions provided by their healthcare provider regarding the management of their anticoagulation therapy during the perioperative period.

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

• Eliquis (apixaban) hold prior to hip replacement: The medication 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, such as hip replacement surgery 2.

From the Research

Eliquis Hold Prior to Hip Replacement

• The decision to hold Eliquis (apixaban) prior to hip replacement surgery depends on various factors, including the patient's individual risk of thrombosis and bleeding 3, 4.
• Studies have shown that apixaban is effective in preventing venous thromboembolism (VTE) after hip or knee replacement surgery, with a similar safety profile to low-molecular-weight heparin (LMWH) 4, 5.
• However, the optimal timing for holding Eliquis prior to surgery is not well established, and the decision should be made on a case-by-case basis, taking into account the patient's specific circumstances and the surgeon's preference 6.

Comparison with Other Anticoagulants

• Apixaban has been compared to other anticoagulants, such as rivaroxaban and dabigatran, in terms of efficacy and safety in preventing VTE after hip or knee replacement surgery 7, 5.
• Rivaroxaban has been shown to have superior efficacy in VTE prevention compared to apixaban and dabigatran, but with a similar safety profile 5.
• The choice of anticoagulant should be based on individual patient factors, such as renal function, liver function, and bleeding risk 3, 7.

Clinical Guidelines

• Clinical guidelines recommend that patients receive at least 10 to 14 days of prophylaxis against VTE after total hip or total knee arthroplasty, using one of several approved agents, including apixaban, rivaroxaban, and LMWH 6.
• The American College of Chest Physicians guidelines recommend shared decision-making with the patient to balance the risk of thrombosis versus bleeding, and to select the most appropriate prophylaxis agent based on individual patient factors 6.