Preoperative Discontinuation of Apixaban and Clopidogrel
Stop clopidogrel 5-7 days before surgery and apixaban 1-2 days before low-to-moderate bleeding risk procedures or 2-3 days before high bleeding risk procedures.
Clopidogrel Discontinuation
Clopidogrel should be stopped 5-7 days prior to most elective surgeries 1. This recommendation is based on the drug's irreversible inhibition of platelet aggregation for the lifetime of the platelet (7-10 days) 2. The Canadian Cardiovascular Society guidelines specifically state that interruption should begin 5-7 days before the procedure, except for procedures with very high bleeding risk where 7-10 days is recommended 1.
For CABG surgery specifically, guidelines recommend stopping clopidogrel at least 5 days preoperatively 3, 4. However, in urgent situations where surgery cannot be delayed, clopidogrel may be stopped 24 hours before surgery to reduce major bleeding, though this increases transfusion risk 4.
The FDA label for Plavix (clopidogrel) states: "When possible, interrupt therapy with Plavix for five days prior to such surgery. Resume Plavix as soon as hemostasis is achieved" 2.
Apixaban Discontinuation
For apixaban, the timing depends on the bleeding risk of the procedure:
Low-to-Moderate Bleeding Risk Procedures
- Stop 1-2 days before surgery (skip 2-4 doses depending on timing) 1, 5
- This allows 2-3 drug half-lives to elapse, resulting in minimal residual anticoagulant effect 6
High Bleeding Risk Procedures
- Stop 2-3 days before surgery (skip 4-6 doses) 1, 5
- This allows 4-5 drug half-lives to elapse, achieving minimal to no residual anticoagulant effect 6
The most recent 2022 CHEST guidelines recommend stopping apixaban 1 day before low-to-moderate-bleed-risk procedures and 2 days before high-bleed-risk procedures 5. The FDA label for Eliquis states that apixaban "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" and "at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding" 7.
Key Considerations
Renal function does not significantly affect apixaban timing (unlike dabigatran), as apixaban has only 25% renal clearance 6. The 2022 CHEST guidelines apply the same timing regardless of renal function for apixaban 5.
No bridging anticoagulation is needed when stopping apixaban due to its rapid offset and onset of action 5, 8. The short half-life (7-8 hours) means therapeutic effect is quickly lost and quickly restored 6.
For neuraxial anesthesia or spinal procedures, consider the longer interruption period (2-3 days minimum) due to the potentially devastating consequences of epidural bleeding 1, 9.