Can a patient on Eliquis (apixaban) go to the Operating Room (OR)?

From the Guidelines

Surgery can be performed on a patient taking Eliquis (apixaban), but timing and management are critical for safety. Elective surgery typically requires discontinuation of Eliquis at least 24-48 hours before the procedure, with longer periods (up to 72 hours) needed for major surgeries or patients with renal impairment, as suggested by the 2018 European Heart Rhythm Association practical guide 1. For emergency surgeries, clinicians must weigh bleeding risks against procedural urgency, as Eliquis has no specific reversal agent widely available. Andexanet alfa may be used in life-threatening situations. Laboratory tests like anti-Factor Xa assays can help assess residual anticoagulant effect. The decision to proceed with surgery while a patient is on Eliquis depends on the bleeding risk of the procedure, the patient's thrombotic risk, and renal function.

Key Considerations

• For minor procedures with low bleeding risk, surgery might proceed with the most recent dose given 24 hours prior.
• Postoperatively, Eliquis is typically restarted 24-48 hours after surgery once adequate hemostasis is achieved, sometimes with initial prophylactic dosing before resuming therapeutic levels, as outlined in the suggested management approach for postoperative resumption of new oral anticoagulants 2.
• The timing of discontinuation and resumption of Eliquis should be judiciously estimated according to the timing of the scheduled procedure to avoid a lack of antithrombotic protection for a prolonged time frame, as noted in the 2016 update on antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention 3.
• Institutional guidelines and hospital-wide policies concerning perioperative anticoagulation management in different surgical settings should be developed and implemented, as strongly recommended by the 2018 European Heart Rhythm Association practical guide 1.

Management Approach

• Discontinuation of Eliquis at least 24-48 hours before elective surgery, with consideration of the patient's renal function and the bleeding risk of the procedure.
• Postoperative resumption of Eliquis 24-48 hours after surgery, with initial prophylactic dosing before resuming therapeutic levels, as suggested by the management approach for postoperative resumption of new oral anticoagulants 2.
• Consideration of the use of andexanet alfa in life-threatening situations where reversal of anticoagulation is necessary.
• Development and implementation of institutional guidelines and hospital-wide policies concerning perioperative anticoagulation management in different surgical settings.

From the FDA Drug Label

2.3 Temporary Interruption for Surgery and Other Interventions 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.

Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required

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

A patient on Eliquis (apixaban) can go to the Operating Room (OR), but 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, or at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding. Apixaban can be restarted after the surgical or other procedures as soon as adequate hemostasis has been established 4.

From the Research

Perioperative Management of Eliquis (Apixaban)

• The management of patients on Eliquis (apixaban) in the perioperative period involves assessing the risk of thromboembolic events while off anticoagulation compared to the relative risk of bleeding if the drug is continued 5.
• For elective surgical or nonsurgical procedures, a standardized approach to perioperative Eliquis management may be applied, classifying the risk of procedure-related bleeding as minimal, low to moderate, or high risk 6.
• Patients undergoing minimal bleeding risk procedures may continue Eliquis, while those undergoing low to moderate bleeding risk procedures should typically discontinue Eliquis 1 day before the operation and restart 1 day after 6.
• For high bleeding risk procedures, Eliquis should be stopped 2 days prior to the operation and restarted 2 days after 6.

Discontinuation of Eliquis Before Surgery

• The timing of Eliquis discontinuation before surgery depends on the type of surgery and the patient's renal function 5, 7.
• For spine surgery, Eliquis should be stopped 2 days prior to the operation 7.
• In general, the decision to discontinue Eliquis should be made on a case-by-case basis, taking into account the individual patient's risk factors and the specific surgical procedure 6, 8.

Management of Bleeding Complications

• In cases of bleeding complications, laboratory testing to measure preoperative Eliquis levels may be useful to determine whether patients should receive a reversal agent 6.
• Tranexamic acid has been shown to reduce perioperative bleeding in elective abdominal surgery, but its use in patients on Eliquis is not well established 9.
• Currently, no antidote exists to reverse the effects of Eliquis, but novel drugs may become available in the future 8.