Timing of Eliquis (Apixaban) Discontinuation Before Surgery
For patients with normal renal function, Eliquis (apixaban) should be discontinued at least 48 hours prior to elective surgery for procedures with low bleeding risk, and at least 72 hours (3 days) prior for procedures with high bleeding risk. 1, 2
Discontinuation Timeline Based on Bleeding Risk
Low Bleeding Risk Procedures
- Last dose: 2 days before surgery (skip 2 doses)
- Minimum discontinuation time: 48 hours
- Examples: minor procedures, dental extractions, skin biopsies
High Bleeding Risk Procedures
- Last dose: 3 days before surgery (skip 4 doses)
- Minimum discontinuation time: 72 hours
- Examples: major abdominal/thoracic surgery, major orthopedic surgery, liver/kidney biopsy
Very High Bleeding Risk Procedures
- Last dose: Up to 5 days before surgery
- Examples: neuraxial anesthesia, spinal procedures, intracranial neurosurgery 2
Special Considerations
Renal Function Impact
While the question specifies normal renal function, it's important to note that apixaban has less dependence on renal clearance than other DOACs, but dosing adjustments are still necessary:
- Normal renal function: Follow standard recommendations above
- Moderate renal impairment (CrCl 30-50 mL/min): Consider extending discontinuation to 3 days for low-risk and 4 days for high-risk procedures 2
Resumption of Anticoagulation
- Resume apixaban when adequate hemostasis is established
- Typically 24-72 hours after surgery depending on bleeding risk
- For procedures with low bleeding risk: Can resume 6+ hours after procedure 2
- For high bleeding risk procedures: Consider delaying resumption for 48-72 hours
Evidence Quality and Practical Considerations
The FDA drug label for apixaban specifically states it 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" 1. This aligns with the French Working Group on Perioperative Hemostasis (GIHP) guidelines, which recommend discontinuation of apixaban 3 days before high bleeding risk procedures 2.
Recent clinical data from the ADIOS study (2022) supports these recommendations, showing that apixaban discontinuation for at least 48 hours resulted in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) prior to surgical procedures 3.
Common Pitfalls to Avoid
No bridging necessary: Unlike warfarin, bridging with heparin is generally not required when stopping apixaban, except in patients with very high thrombotic risk (e.g., recent VTE within 3 months) 2
Avoid laboratory monitoring: Standard coagulation tests (PT/INR, aPTT) are not reliable for monitoring apixaban activity
Consider procedure urgency: For emergency procedures, factor in the increased bleeding risk and consider prothrombin complex concentrate if reversal is needed
Don't use a one-size-fits-all approach: The 48-72 hour window is for normal renal function; patients with impaired renal function require longer discontinuation periods
By following these evidence-based recommendations for timing Eliquis discontinuation before surgery, you can minimize both bleeding risk during the procedure and thrombotic risk from extended anticoagulation interruption.