When to Hold Eliquis (Apixaban) Before Procedures
For patients taking Eliquis (apixaban) who require procedures, the medication should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate to high bleeding risk, and at least 24 hours prior to procedures with low bleeding risk. 1
Procedure-Based Timing for Holding Apixaban
High Bleeding Risk Procedures (hold for at least 48 hours)
- Urologic or GI surgery, especially with anastomosis
- Transurethral prostate or bladder resection
- Nephrectomy, kidney biopsy
- Colonic polyp resection or bowel resection
- Percutaneous endoscopic gastrostomy placement
- Endoscopic retrograde cholangiopancreatography
- Surgery in highly vascular organs (kidneys, liver, spleen)
- Cardiac, intracranial, or spinal surgery
- Any major operation (procedure duration > 45 min)
- Neuraxial anesthesia or epidural injections 2
Low-to-Moderate Bleeding Risk Procedures (hold for at least 24 hours)
- Arthroscopy
- Cutaneous/lymph node biopsies
- Foot/hand surgery
- Coronary angiography
- GI endoscopy biopsy
- Colonoscopy biopsy
- Abdominal hysterectomy
- Laparoscopic cholecystectomy
- Abdominal hernia repair
- Hemorrhoidal surgery
- Bronchoscopy biopsy 2, 1
Minimal Bleeding Risk Procedures (may continue apixaban)
- Minor dermatologic procedures
- Ophthalmologic (cataract) procedures
- Minor dental procedures
- Dental cleanings
- Pacemaker or cardioverter-defibrillator implantation 2
Special Considerations
Renal Function
Unlike dabigatran, apixaban does not require extended interruption times for patients with impaired renal function, as it has less renal dependence for elimination 2.
Neuraxial Anesthesia
For procedures involving neuraxial anesthesia or spinal puncture, special caution is warranted due to the risk of spinal/epidural hematoma:
- Ensure complete cessation of apixaban effect (minimum 48 hours, preferably longer)
- Consider the potentially devastating consequences of epidural bleeding 2, 1
Resumption of Anticoagulation
- For low bleeding risk procedures: Resume apixaban at least 6 hours after the procedure if hemostasis is adequate 2
- For high bleeding risk procedures: Delay resumption for 48-72 hours and consider bridging with prophylactic dose heparin if thrombotic risk is high 2
Evidence Quality and Clinical Implications
The 2022 American College of Chest Physicians guidelines provide the most recent and authoritative recommendations 2. These guidelines are supported by observational data showing that discontinuation of apixaban for at least 48 hours before procedures results in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) 3.
Common Pitfalls to Avoid
Unnecessary bridging: The rapid offset and onset of action of apixaban generally obviates the need for bridging with heparin in the perioperative setting 2.
Inadequate hold time for neuraxial procedures: Neuraxial anesthesia requires complete cessation of anticoagulant effect due to the catastrophic consequences of spinal hematoma.
Premature resumption: Restarting apixaban too early after procedures with poor hemostasis can lead to significant bleeding complications.
One-size-fits-all approach: While guidelines provide general recommendations, the bleeding risk of specific procedures must be considered individually.
Failure to account for drug interactions: Patients on combined P-gp and strong CYP3A4 inhibitors may have prolonged apixaban effect and may require longer hold times 1.
By following these evidence-based recommendations for perioperative management of apixaban, clinicians can minimize both bleeding and thrombotic complications in patients undergoing procedures.