What is the recommended anticoagulation management for a patient on Eliquis (apixaban) with a history of pulmonary embolism (PE) undergoing arthroscopic knee surgery?

From the Guidelines

For a patient on Eliquis (apixaban) with a history of pulmonary embolism undergoing arthroscopic knee surgery, the risk of pulmonary embolism when stopping Eliquis can be mitigated by resuming apixaban 24 hours postoperatively at a dose of 5 mg twice daily, or considering a reduced dose of 2.5 mg twice daily for patients at high risk for thromboembolism, as suggested by management approaches 1. The management of anticoagulation in patients undergoing surgery is crucial to balance the risk of bleeding and thromboembolism.

• Arthroscopic knee surgery is generally considered a low-to-moderate bleeding risk procedure.
• The risk of pulmonary embolism in patients with a history of PE is a significant concern when stopping anticoagulation therapy.
• According to the suggested management approach, apixaban can be resumed 24 hours postoperatively at a dose of 5 mg twice daily for patients undergoing low bleeding risk surgery, such as arthroscopic knee surgery 1.
• For patients at high risk for thromboembolism, a reduced dose of apixaban (2.5 mg twice daily) may be considered, as indicated in the management approach 1.
• Close monitoring for signs of bleeding or thrombosis is essential during the perioperative period to promptly address any complications that may arise.
• Bridging anticoagulation with heparin may be considered for patients with recent PE (within 3 months) or other high thrombotic risk factors, but this is not typically necessary for most patients on apixaban undergoing arthroscopic knee surgery.

From the FDA Drug Label

Premature discontinuation of any oral anticoagulant, including apixaban, increases the risk of thrombotic events If anticoagulation with apixaban is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant 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

The risk of pulmonary embolism for a patient with a previous history of PE when stopping Eliquis for arthroscopic knee surgery is increased due to the premature discontinuation of apixaban.

• Key consideration: The patient's history of pulmonary embolism puts them at a higher risk for recurrent thrombotic events.
• Recommendation: Consider coverage with another anticoagulant when discontinuing apixaban for surgery, and restart apixaban as soon as adequate hemostasis has been established after the procedure 2.

From the Research

Anticoagulation Management for Patients with a History of Pulmonary Embolism Undergoing Arthroscopic Knee Surgery

The management of anticoagulation in patients with a history of pulmonary embolism (PE) who are undergoing arthroscopic knee surgery is crucial to prevent recurrent PE and minimize the risk of bleeding.

• The risk of recurrent PE in patients with a history of PE is significant, and anticoagulation therapy is essential to reduce this risk 3, 4.
• For patients on Eliquis (apixaban) with a history of PE, the decision to stop anticoagulation therapy for arthroscopic knee surgery should be made on a case-by-case basis, considering the individual patient's risk factors and the potential benefits and risks of stopping anticoagulation 5, 6.
• The American College of Chest Physicians (ACCP) guidelines recommend that patients with a history of PE who are undergoing surgery should receive bridging anticoagulation therapy with a low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) if the risk of recurrent PE is high 3.
• However, the use of bridging anticoagulation therapy in patients undergoing arthroscopic knee surgery is not well established, and the decision to use bridging therapy should be individualized based on the patient's risk factors and the surgeon's preference 7.

Recommended Anticoagulation Regimen

• For patients with a history of PE who are undergoing arthroscopic knee surgery, the recommended anticoagulation regimen is to stop Eliquis (apixaban) 24 to 48 hours before surgery and restart it as soon as possible after surgery, usually within 24 hours 5, 6.
• The use of bridging anticoagulation therapy with a LMWH or UFH may be considered in patients with a high risk of recurrent PE, but this should be individualized based on the patient's risk factors and the surgeon's preference 3, 7.
• It is essential to monitor the patient's renal function and adjust the dose of Eliquis (apixaban) accordingly to minimize the risk of bleeding 4, 6.

Risk of Pulmonary Embolism

• The risk of pulmonary embolism in patients with a history of PE who are undergoing arthroscopic knee surgery is significant, and anticoagulation therapy is essential to reduce this risk 3, 4.
• The risk of recurrent PE can be minimized by using a direct oral anticoagulant (DOAC) such as apixaban, which has been shown to be effective in reducing the risk of recurrent PE 5, 6.
• However, the risk of bleeding should also be considered, and the decision to stop anticoagulation therapy for arthroscopic knee surgery should be made on a case-by-case basis, considering the individual patient's risk factors and the potential benefits and risks of stopping anticoagulation 7, 5.