How long should Eliquis (apixaban) be held before surgery in a patient with normal renal function?

Timing for Holding Eliquis (Apixaban) Before Surgery

For patients with normal renal function, Eliquis (apixaban) should be discontinued at least 48 hours prior to elective surgery with a moderate to high risk of bleeding, and at least 24 hours prior to procedures with a low risk of bleeding. 1

Detailed Recommendations Based on Surgical Bleeding Risk

High Bleeding Risk Procedures

• Hold apixaban for 3 days before surgery (skip 4 doses) 2
• This timing allows for 4-5 half-lives to elapse, ensuring minimal anticoagulant effect during surgery
• Examples of high bleeding risk procedures:
  • Major surgery
  • Neuraxial anesthesia (spinal/epidural)
  • Intracranial surgery
  • Major orthopedic procedures

Low Bleeding Risk Procedures

• Hold apixaban for 2 days before surgery (skip 2 doses) 2
• This provides sufficient clearance while minimizing thrombotic risk
• Examples of low bleeding risk procedures:
  • Minor procedures
  • Procedures where bleeding is easily controlled

Special Considerations

Renal Function Impact

While the question specifies normal renal function, it's important to note that:

• Apixaban has a half-life of 7-8 hours in patients with normal renal function 2
• Unlike dabigatran, apixaban is less dependent on renal clearance 2
• Recent research shows that discontinuation for at least 48 hours results in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) 3

Neuraxial Anesthesia

• If neuraxial anesthesia is planned, a longer interruption period is strongly recommended 2
• The French Working Group on Perioperative Hemostasis (GIHP) recommends up to 5 days for "xabans" prior to neuraxial procedures 2

Bridging Anticoagulation

• Bridging with heparin is generally not required when holding apixaban 2
• Exception: Consider bridging only in patients with very high thrombotic risk, such as recent (<3 months) venous thromboembolism 2

Resumption After Surgery

• Resume apixaban when adequate hemostasis is achieved 1
• For most procedures, this is typically 24-72 hours postoperatively 2
• If venous thromboprophylaxis is indicated immediately post-op, consider heparin or LMWH starting 6 hours after procedure completion 2

Common Pitfalls to Avoid

1. Insufficient holding time: Failing to hold apixaban long enough before high-risk procedures can lead to increased bleeding risk
2. Unnecessary bridging: Unlike warfarin, apixaban has a shorter half-life and typically doesn't require bridging therapy
3. One-size-fits-all approach: Not adjusting holding time based on bleeding risk of the procedure
4. Delayed resumption: Unnecessarily prolonged postoperative anticoagulant interruption increases thrombotic risk

The FDA label specifically states that apixaban should be discontinued at least 48 hours prior to elective surgery with moderate/high bleeding risk and at least 24 hours prior to procedures with low bleeding risk 1, which aligns with the clinical guidelines reviewed.