What is the recommended management of Eliquis (apixaban) in a 71-year-old female with normal renal function undergoing total knee replacement surgery?

From the Guidelines

For a 71-year-old female with normal renal function undergoing total knee replacement surgery who is on Eliquis (apixaban), the recommended management is to discontinue Eliquis 48 hours before the scheduled surgery and resume it 24 hours after surgery once hemostasis is achieved, as per the most recent guidelines 1.

Perioperative Management of Apixaban

The management of apixaban in the perioperative period for patients undergoing total knee replacement surgery involves careful consideration of the bleeding risk and thrombotic risk.

• The patient should stop taking apixaban 48 hours before the surgery, as indicated in the guidelines for high bleeding risk procedures 1.
• Postoperatively, apixaban should be resumed 24 hours after surgery, once hemostasis is achieved, at a dose of 2.5 mg twice daily for thromboprophylaxis 1.

Thromboprophylaxis Regimen

The thromboprophylaxis regimen with apixaban should be continued for 10-14 days after surgery, and may be extended up to 35 days for knee replacement surgery, depending on the individual patient's risk factors 1.

Mechanical Prophylaxis

Mechanical prophylaxis with compression stockings or intermittent pneumatic compression devices should be used during the perioperative period to reduce the risk of venous thromboembolism 1.

Bleeding Risk Management

The management of bleeding risk is crucial in the perioperative period, and the use of apixaban should be carefully balanced against the risk of bleeding, as per the guidelines 1.

• The patient's renal function should be closely monitored, and the dose of apixaban adjusted accordingly, if necessary.
• The patient should be closely monitored for signs of bleeding or thrombosis, and the apixaban dose adjusted or discontinued as needed.

From the FDA Drug Label

In the ADVANCE-2 study, the first dose of apixaban was given 12 to 24 hours post surgery, whereas enoxaparin was started 9 to 15 hours prior to surgery. In the ADVANCE-1 study, both apixaban and enoxaparin were initiated 12 to 24 hours post surgery.

The patient should stop taking Eliquis (apixaban) at least 9 to 15 hours before the total knee replacement surgery, however the exact timing for stopping is not explicitly stated in the label for patients already on the medication. After surgery, Eliquis can be restarted 12 to 24 hours post-surgery 2.

From the Research

Management of Eliquis (Apixaban) in Total Knee Replacement Surgery

• The management of Eliquis (apixaban) in a 71-year-old female with normal renal function undergoing total knee replacement surgery should be based on the recommended guidelines for the prevention of venous thromboembolism (VTE) 3, 4, 5.
• Apixaban is an orally active and selective direct inhibitor of factor Xa, which has been approved for the prevention of VTE in patients undergoing elective total hip or knee replacement surgery 3, 4.
• The recommended dosage of apixaban for VTE prevention is 2.5 mg twice daily, initiated 12-24 hours after wound closure 3, 4, 5.
• However, the timing of stopping apixaban before surgery is not explicitly stated in the provided studies, but it is generally recommended to stop anticoagulant therapy before surgery to minimize the risk of bleeding 6.
• The decision to stop apixaban before surgery should be made based on the individual patient's risk of bleeding and thromboembolism, as well as the surgical procedure and anesthesia planned 6.
• After surgery, apixaban can be restarted 12-24 hours after wound closure, as soon as it is safe to do so, to prevent VTE 3, 4, 5.

Comparison with Enoxaparin

• Apixaban has been compared to enoxaparin, a low-molecular-weight heparin, in several studies, and has been shown to be effective in preventing VTE with a similar or lower risk of bleeding 4, 7, 5.
• A pooled analysis of two studies found that apixaban was more effective than enoxaparin in preventing major VTE, without increasing the risk of bleeding 5.
• Another study found that apixaban was an effective alternative to enoxaparin as a thromboprophylactic drug for patients undergoing elective total knee replacement surgery, with no statistically significant differences in minor and major surgical wound complications and DVT incidence 7.

Special Considerations

• Patients with renal failure are at risk of overdose with apixaban, and dose adjustments may be necessary 6.
• Apixaban has a high potential for pharmacokinetic interactions, and caution should be exercised when using it in combination with other medications 6.
• There is no known antidote for apixaban, and reversal of anticoagulation may be difficult in the event of bleeding 6.