How long should Eliquis (apixaban) be held before surgery in patients with impaired renal function?

From the Guidelines

For patients with impaired renal function taking Eliquis (apixaban), the medication should generally be held for at least 48 hours before major surgery and at least 24 hours before minor surgery, as recommended by the most recent guidelines 1. The decision to hold Eliquis before surgery should be based on the severity of renal impairment, with consideration of extending the discontinuation period to 72 hours before major surgery for patients with severe renal impairment (creatinine clearance less than 30 mL/min) due to delayed drug clearance 1. Key factors to consider when determining the timing of Eliquis discontinuation include:

• The patient's individual bleeding risk
• The specific surgical procedure
• The risk of thrombotic events if anticoagulation is interrupted
• The severity of renal impairment, as apixaban is partially eliminated by the kidneys (approximately 27%) 1 It is essential to consult with both the surgeon and cardiologist before adjusting anticoagulation, as some patients may need bridging therapy during the perioperative period 1. In cases where the prediction of NOAC clearance is unclear, measurement of NOAC plasma levels may be considered, and the planned surgical intervention should only proceed when the level is considered low enough 1. However, it is crucial to note that the determination of 'safe' NOAC levels in this setting lacks an evidence base, and waiting for levels to drop into that range while accepting the inherent risk of thromboembolism during that time is a consideration 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.

Eliquis (apixaban) should be held for at least 48 hours before surgery in patients with impaired renal function who are at a moderate or high risk of bleeding, and at least 24 hours for those at a low risk of bleeding 2.

From the Research

Eliquis (Apixaban) Hold Time Before Surgery

The hold time for Eliquis (apixaban) before surgery in patients with impaired renal function is not explicitly stated in the provided studies. However, the following points can be considered:

• The pharmacokinetics and pharmacodynamics of apixaban are affected by renal impairment, and the drug is partially cleared by the kidneys 3.
• Studies have shown that apixaban can be safely used in patients with mild to moderate renal impairment, but the risk of bleeding may be increased in patients with severe renal impairment 4, 5.
• The American College of Cardiology recommends holding apixaban for at least 24 to 48 hours before surgery, depending on the patient's renal function and the type of surgery 6.
• The following factors should be considered when determining the hold time for apixaban before surgery:
  • Renal function: Patients with severe renal impairment may require a longer hold time due to the increased risk of bleeding.
  • Type of surgery: The hold time may be longer for surgeries with a high risk of bleeding, such as cardiac or neurosurgery.
  • Patient's overall health: Patients with multiple comorbidities or those taking concomitant medications that increase the risk of bleeding may require a longer hold time.

Key Considerations

• Patients with impaired renal function should be closely monitored for signs of bleeding during the hold time and after surgery.
• The hold time for apixaban should be individualized based on the patient's specific clinical characteristics and the type of surgery.
• Clinicians should consult the patient's medical history, laboratory results, and current medications to determine the optimal hold time for apixaban before surgery.
• It is essential to weigh the risks and benefits of holding apixaban before surgery, as the drug is used to prevent thromboembolic events, and holding it for an extended period may increase the risk of these events 7, 4.