Eliquis Discontinuation Before Elective Hip Surgery
For elective hip replacement surgery, hold apixaban (Eliquis) for 2 days (48 hours) prior to surgery if the patient has normal renal function (CrCl >50 mL/min), or extend to 3-4 days if renal impairment exists (CrCl 30-50 mL/min).
Evidence-Based Timing
The most recent and highest-quality evidence comes from the 2022 American College of Chest Physicians guidelines 1, which established standardized DOAC interruption protocols based on the landmark PAUSE study. This prospective management study of 3,007 patients demonstrated that apixaban interrupted for 2 days before high-bleed-risk surgery (which includes hip replacement) resulted in only 0.16% arterial thromboembolism and 1.35% major bleeding at 30 days 1.
The FDA label for Eliquis 2 recommends discontinuation at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding, which hip replacement clearly represents.
Renal Function Considerations
Your approach must be stratified by creatinine clearance:
- CrCl >50 mL/min: Hold for 2 days (48 hours) before surgery
- CrCl 30-50 mL/min: Extend hold to 3-4 days before surgery
- CrCl <30 mL/min: Consider 4-5 days interruption and potentially measure apixaban levels 1
The French GIHP guidelines 3 align with this approach, recommending 2-day interruption for standard patients but extending to 5 days for those with renal impairment or taking P-glycoprotein inhibitors.
Critical Timing Details
Calculate the hold period from the last dose taken, not from when you write the order:
- If the patient takes apixaban twice daily (standard dosing), the last dose should be approximately 48 hours before the scheduled surgical incision time
- For a morning surgery, this means the last dose would be taken 2 mornings prior
- Account for the patient's actual dosing schedule (morning/evening) when calculating
Additional Patient-Specific Factors Requiring Extended Hold
Extend the interruption period to 3-5 days if the patient has:
- Age ≥80 years (particularly relevant for hip replacement patients)
- Concomitant P-glycoprotein inhibitors (verapamil, amiodarone, dronedarone, quinidine)
- CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir) 3
- Body weight extremes (particularly <60 kg)
No Bridging Required
Do not bridge with heparin or LMWH during the interruption period 1, 3, 2. The PAUSE study demonstrated excellent outcomes without bridging, and bridging increases bleeding risk without reducing thrombotic events. The only exception would be patients at very high thrombotic risk, which should be determined through multidisciplinary discussion.
Neuraxial Anesthesia Considerations
If spinal or epidural anesthesia is planned, the French guidelines 3 strongly recommend against performing neuraxial procedures unless adequate discontinuation time has elapsed, particularly in elderly patients or those with renal impairment. This is a critical safety consideration for hip replacement surgery where neuraxial techniques are commonly used.
Verification Before Surgery
The 2022 ADIOS study 4 demonstrated that in real-world practice, 94% of patients achieved clinically insignificant apixaban levels (≤30 ng/mL) after a median hold of 76 hours. However, one patient with a 59-hour hold still had elevated levels. This supports the 48-hour minimum but highlights that patients with risk factors may need longer interruption periods.
Common Pitfalls to Avoid
- Don't count calendar days incorrectly: 48 hours means two full half-lives have passed, not "skip one day"
- Don't forget to check recent creatinine: Renal function may have changed since the patient started apixaban
- Don't assume all DOACs are the same: Dabigatran requires longer interruption (4 days) due to renal elimination 1
- Don't bridge reflexively: This is outdated practice that increases bleeding risk
Resumption After Surgery
Plan to restart apixaban 24-72 hours postoperatively once surgical hemostasis is established 3, 2. For hip replacement specifically, prophylactic-dose anticoagulation (LMWH or fondaparinux) can begin 6 hours postoperatively, with therapeutic apixaban resuming 12 hours after the last prophylactic dose 3.