From the Guidelines
Apixaban should be discontinued at least 48 hours before elective hernia repair surgery for patients with normal renal function, and 72 hours before surgery for those with impaired kidney function, to minimize bleeding risk. When considering the management of anticoagulation in patients taking apixaban (Elequis) prior to hernia repair surgery, it's crucial to balance the risk of bleeding against the risk of thrombotic events. The decision on when to stop apixaban is guided by the patient's renal function, as this affects the drug's clearance. For patients with normal renal function (creatinine clearance ≥50 mL/min), stopping apixaban 48 hours before surgery is generally recommended, as this allows for a significant decrease in drug levels, minimizing the risk of perioperative bleeding 1. However, for patients with impaired renal function (creatinine clearance <50 mL/min), a longer period of 72 hours may be necessary before surgery to ensure that the drug has been adequately cleared from the system, given its prolonged half-life in such patients. Bridging anticoagulation with heparin is not typically required for most patients but may be considered on a case-by-case basis, especially for those with a high risk of thrombotic events, such as recent venous thromboembolism, mechanical heart valves, or recent stroke, after consultation with a specialist 1. Apixaban can usually be resumed 24-48 hours after surgery, once adequate hemostasis has been achieved, with the timing dependent on both the surgical bleeding risk and the patient's thrombotic risk profile. This approach is supported by the relatively short half-life of apixaban, which allows for rapid adjustment of anticoagulation levels, thus minimizing the risk of both bleeding and thrombotic complications. Key considerations include:
- Patient's renal function
- Timing of apixaban discontinuation before surgery
- Assessment of thrombotic risk
- Decision on bridging anticoagulation
- Timing of apixaban resumption after surgery. Given the most recent and highest quality evidence, the management strategy for apixaban in the context of hernia repair surgery prioritizes minimizing bleeding risk while considering the patient's overall thrombotic risk profile 1.
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 [see Warnings and Precautions (5. 2)] . 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.
For a patient taking Elequis (apixaban) prior to hernia repair surgery, apixaban should be discontinued at least 48 hours prior to elective surgery if the surgery has a moderate or high risk of unacceptable or clinically significant bleeding, or at least 24 hours prior to elective surgery if the surgery has a low risk of bleeding. Apixaban can be restarted after the surgical procedure as soon as adequate hemostasis has been established 2.
- Key considerations:
- Timing of apixaban discontinuation
- Risk of bleeding associated with the surgical procedure
- Restarting apixaban after surgery
- Clinical decision: Discontinue apixaban at least 24 to 48 hours before hernia repair surgery, depending on the risk of bleeding, and restart after adequate hemostasis has been established.
From the Research
Pre-operative Anticoagulation Management for Hernia Repair Surgery
The patient is taking Elequis (apixaban) and requires pre-operative clearance for hernia repair surgery. The following points should be considered:
- Bleeding Risk: The risk of bleeding associated with apixaban should be assessed, as well as the risk of thromboembolism if anticoagulation is interrupted 3.
- Renal Function: The patient's renal function should be evaluated, as apixaban is contraindicated in patients with severe renal impairment 4.
- Alternative Anticoagulants: The use of low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKAs) as alternative anticoagulants should be considered, taking into account the patient's renal function and bleeding risk 5, 6, 7.
- Perioperative Management: A strategy that considers the pharmacokinetic properties of apixaban, the bleeding risk of the procedure, and patient renal function should be developed to safely manage anticoagulation during the perioperative period 3.
Key Considerations
- Apixaban has been shown to be effective and safe in patients with severe renal failure, with a lower risk of bleeding compared to warfarin 4.
- LMWH and VKAs have been used as alternative anticoagulants in patients with renal impairment, but their use should be carefully considered due to the risk of bleeding and thromboembolism 5, 6, 7.
- The patient's individual risk factors, such as age, comorbidities, and medication use, should be taken into account when developing a perioperative anticoagulation management plan.
Recommendations
- Consult with a hematologist or cardiologist to develop a personalized perioperative anticoagulation management plan.
- Consider the use of apixaban or alternative anticoagulants, such as LMWH or VKAs, based on the patient's renal function and bleeding risk.
- Monitor the patient closely for signs of bleeding or thromboembolism during the perioperative period.