How long should Eliquis (apixaban) be stopped before a procedure based on evidence?

How Long to Stop Eliquis Before Procedures

For patients taking Eliquis (apixaban), discontinue the medication for 1-3 days before procedures depending on bleeding risk: 1 day before low-bleeding-risk procedures and 2-3 days before high-bleeding-risk procedures. 1

Perioperative Management Algorithm Based on Bleeding Risk

Procedure Bleeding Risk Classification

High Bleeding Risk Procedures (stop Eliquis 2-3 days before):

• Major surgeries (procedure duration >45 min)
• Neuraxial anesthesia/epidural procedures
• Intracranial or spinal surgery
• Major cancer surgery
• Surgery involving highly vascular organs (kidneys, liver, spleen)
• Bowel resection
• Endoscopic procedures with high bleeding risk (polypectomy, sphincterotomy)

Low-to-Moderate Bleeding Risk Procedures (stop Eliquis 1 day before):

• Arthroscopy
• Biopsies (cutaneous, lymph node)
• Coronary angiography
• Colonoscopy without polypectomy
• Laparoscopic cholecystectomy
• Abdominal hernia repair

Minimal Bleeding Risk Procedures (may continue Eliquis):

• Minor dental procedures
• Cataract surgery
• Minor dermatologic procedures
• Pacemaker implantation

Specific Timing Recommendations

1. High Bleeding Risk Procedures:

   • Stop Eliquis 2 days before the procedure 1
   • For very high bleeding risk procedures (intracranial neurosurgery or neuraxial anesthesia), consider stopping up to 3-5 days before 1

2. Low-to-Moderate Bleeding Risk Procedures:

   • Stop Eliquis 1 day before the procedure 1

3. Minimal Bleeding Risk Procedures:

   • May continue Eliquis or hold only the morning dose on the day of procedure 1

Special Considerations

Renal Function

• Unlike dabigatran, apixaban does not require extended interruption periods for patients with renal impairment 1
• Standard discontinuation timing applies regardless of renal function

Bridging Anticoagulation

• No heparin bridging is required when stopping Eliquis before procedures 1
• The rapid offset and onset of action of Eliquis eliminates the need for bridging with short-acting anticoagulants 1

Resumption After Procedure

• For low-to-moderate bleeding risk procedures: resume at least 24 hours after procedure 1
• For high bleeding risk procedures: resume 48-72 hours after procedure 1
• Remember that Eliquis has a rapid onset of action with peak effect occurring 1-3 hours after intake 1

Recent Evidence

Recent research supports these recommendations. The ADIOS study (2022) demonstrated that discontinuing apixaban for at least 48 hours before procedures resulted in clinically insignificant levels of anticoagulation, with 94% of patients achieving apixaban concentrations ≤30 ng/mL 2. This study showed very low rates of perioperative bleeding and thromboembolic events, supporting the safety of this approach.

Common Pitfalls to Avoid

• Pitfall #1: Applying the same discontinuation protocol for all DOACs. Each DOAC has specific recommendations.
• Pitfall #2: Unnecessary bridging with heparin, which increases bleeding risk without reducing thrombotic risk.
• Pitfall #3: Resuming Eliquis too early after high bleeding risk procedures, which can increase bleeding complications due to its rapid onset of action.
• Pitfall #4: Failing to account for the specific bleeding risk of the procedure when determining discontinuation timing.

The FDA label for apixaban specifically states that it should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding, and at least 24 hours prior to procedures with low risk of bleeding 3.