When should Eliquis (apixaban) be stopped before surgery in patients with normal or impaired renal function?

When to Stop Eliquis (Apixaban) Before Surgery

For patients on Eliquis (apixaban), stop the medication 48 hours before high bleeding risk procedures and 24 hours before low bleeding risk procedures, regardless of renal function.

Timing of Apixaban Discontinuation Based on Bleeding Risk

Low to Moderate Bleeding Risk Procedures

• Stop apixaban 24 hours before the procedure (skip 2 doses) 1
• Examples: minor dental procedures, endoscopy without biopsy, cataract surgery, minor skin procedures

High Bleeding Risk Procedures

• Stop apixaban 48 hours before the procedure (skip 4 doses) 1
• Examples: major abdominal surgery, major orthopedic surgery, cardiac surgery, neurosurgery

Very High Bleeding Risk Procedures

• For procedures with potentially catastrophic bleeding consequences (intracranial neurosurgery, spinal surgery with neuraxial anesthesia), consider extending discontinuation to 3-5 days 1

Impact of Renal Function

Unlike dabigatran, apixaban's clearance is less dependent on renal function, so the discontinuation timing remains the same regardless of creatinine clearance 1:

• Normal renal function: 48 hours before high-risk procedures
• Impaired renal function (CrCl 15-50 mL/min): 48 hours before high-risk procedures

This is a key advantage of apixaban compared to dabigatran, which requires longer discontinuation periods (up to 4 days) in patients with impaired renal function 1.

Perioperative Management Algorithm

1. Assess bleeding risk of the planned procedure
2. Determine timing of last dose:
   • Low bleeding risk: Last dose 24 hours before procedure
   • High bleeding risk: Last dose 48 hours before procedure
3. No bridging anticoagulation is needed due to apixaban's short half-life 1
4. Resume apixaban when adequate hemostasis is achieved:
   • Low bleeding risk: Resume ≥6 hours after procedure 1
   • High bleeding risk: Resume 48-72 hours after procedure 1

Important Clinical Considerations

• Apixaban has a rapid onset of action (1-3 hours), so timing of post-procedure resumption is critical 1
• For twice-daily regimens, the last dose should be on the morning of the day before the planned procedure 1
• For procedures with minimal bleeding risk (e.g., simple dental extractions, skin biopsies), consider continuing apixaban 2
• Recent data from the ADIOS study showed that apixaban discontinuation for at least 48 hours resulted in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) 3

Common Pitfalls to Avoid

1. Unnecessary bridging: Unlike warfarin, apixaban does not require bridging with heparin during the perioperative period 1
2. Excessive discontinuation: Stopping apixaban for longer than necessary increases thrombotic risk
3. Inadequate discontinuation: Not stopping apixaban long enough before high-risk procedures increases bleeding risk
4. Premature resumption: Restarting apixaban too soon after surgery can lead to bleeding complications due to its rapid onset of action
5. Failure to consider drug interactions: P-gp and strong CYP3A4 inhibitors can increase apixaban levels and may require longer discontinuation periods 4

Remember that these recommendations apply to elective procedures. For emergency procedures, laboratory testing of apixaban levels may be necessary to determine if reversal agents are needed 1.