What are the perioperative management guidelines for a patient on Eliquis (apixaban) undergoing mandibulectomy?

From the Guidelines

Perioperative management of apixaban (Eliquis) for a patient undergoing mandibulectomy requires careful planning to balance bleeding and thrombotic risks, with apixaban typically discontinued 48 hours before the procedure for patients with normal renal function, or 72 hours before for those with impaired renal function (CrCl <50 mL/min) 1. The management approach should consider the patient's specific comorbidities, indication for anticoagulation, and surgical bleeding risk.

• Bridging therapy with heparin is generally not recommended unless the patient has a very high thrombotic risk.
• Laboratory testing (PT, aPTT, and anti-Factor Xa levels) may be performed preoperatively to confirm adequate drug clearance.
• After surgery, apixaban can usually be resumed 24-72 hours postoperatively once hemostasis is achieved, with the exact timing depending on the bleeding risk associated with the procedure and the patient's thrombotic risk 1. Some key points to consider in the perioperative management of apixaban include:
• The use of mechanical thromboprophylaxis with compression devices during the perioperative period.
• The consideration of prothrombin complex concentrate (25-50 IU/kg) or andexanet alfa to reverse anticoagulation effects in emergency procedures 1.
• Close collaboration between the surgeon, anesthesiologist, and the patient's cardiologist or primary physician is essential to develop an individualized perioperative plan 1. The most recent and highest quality study, 1, provides guidance on the perioperative management of direct oral anticoagulants, including apixaban, and should be consulted for specific recommendations on management.

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. Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.

The perioperative management guidelines for a patient on Eliquis (apixaban) undergoing mandibulectomy are to discontinue apixaban at least 48 hours prior to surgery due to the moderate to high risk of bleeding associated with this procedure.

• The patient should stop taking apixaban 48 hours before the mandibulectomy.
• Bridging anticoagulation is not generally required during the 24 to 48 hours after stopping apixaban and prior to the intervention.
• Apixaban should be restarted after the surgical procedure as soon as adequate hemostasis has been established 2.

From the Research

Perioperative Management Guidelines for Patients on Eliquis (Apixaban)

The management of patients on Eliquis (apixaban) undergoing surgical procedures, such as mandibulectomy, requires careful consideration of the risk of bleeding and thromboembolism.

• The decision to discontinue apixaban before surgery should be made in consultation with the patient's general practitioner or cardiologist, weighing the risk of bleeding against the risk of thrombosis or stroke 3.
• A study on apixaban discontinuation for invasive or major surgical procedures found that discontinuing apixaban for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to surgery 4.
• For patients with mechanical prosthetic heart valves on long-term oral anticoagulants, bridging anticoagulant therapy with unfractionated heparin or low-molecular-weight heparin may be recommended 5.
• The choice of anticoagulant and the timing of its discontinuation should be individualized based on the patient's specific risk factors and the type of surgery being performed.
• Local measures to favor coagulation, such as the use of hemostatic agents, and careful monitoring of the patient's bleeding risk can help minimize the risk of bleeding complications 3.

Considerations for Patients on Apixaban Undergoing Oral Surgery

• Patients on apixaban undergoing oral surgery, such as mandibulectomy, should have their anticoagulation therapy managed carefully to minimize the risk of bleeding complications.
• The timing of apixaban discontinuation and the use of bridging anticoagulant therapy should be determined on a case-by-case basis, taking into account the patient's individual risk factors and the type of surgery being performed.
• A review of the literature on patients taking direct oral anticoagulants, including apixaban, undergoing oral surgery found that careful planning and management of anticoagulation therapy can help minimize the risk of bleeding complications 3.
• The use of apixaban has been shown to be effective in preventing recurrent venous thromboembolism in patients with cancer-associated thromboembolism, with a lower risk of recurrent VTE compared to low-molecular-weight heparin 6.