How long should Eliquis (apixaban) be held before surgery?

Timing of Apixaban (Eliquis) Discontinuation Before Surgery

For patients taking apixaban (Eliquis), discontinue the medication 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

Discontinuation Timeline Based on Bleeding Risk and Renal Function

High Bleeding Risk Procedures

• Normal or mild renal impairment (CrCl ≥50 mL/min):

  • Last dose: 3 days before surgery (skip 4 doses) 2
  • This allows 4-5 half-lives to elapse, ensuring minimal anticoagulant effect

• Moderate renal impairment (CrCl 30-50 mL/min):

  • Last dose: 4 days before surgery (skip 6 doses) 2
  • Extended discontinuation time accounts for slower drug clearance

Low Bleeding Risk Procedures

• Normal or mild renal impairment (CrCl ≥50 mL/min):

  • Last dose: 2 days before surgery (skip 2 doses) 2
  • Allows 2-3 half-lives to elapse with acceptable residual anticoagulant effect

• Moderate renal impairment (CrCl 30-50 mL/min):

  • Last dose: 3 days before surgery (skip 4 doses) 2

Very High Bleeding Risk Procedures

• For neuraxial anesthesia, intracranial neurosurgery, or other very high bleeding risk procedures:
  • Consider longer discontinuation periods (up to 5 days) 2
  • Consider measuring apixaban levels if available

Special Considerations

• Dental procedures: For minor dental procedures (scaling, root planing), apixaban can be continued without interruption as these are considered low bleeding risk 3

• Pharmacokinetics: Apixaban has a half-life of approximately 12 hours, with consistent pharmacokinetics across a broad range of patients 4

• Bridging: No preoperative bridging with heparin is required when apixaban is discontinued 2

• Resumption after surgery:

  • Resume apixaban when adequate hemostasis is established, typically at least 6 hours after the end of the procedure 2, 1
  • For high bleeding risk procedures, consider starting with prophylactic doses of heparin or LMWH first, then transitioning to apixaban 2

Clinical Evidence Supporting Recommendations

Research supports that discontinuing apixaban for at least 48 hours before surgery results in clinically insignificant levels of anticoagulation. In a prospective study, 94% of patients had apixaban concentrations ≤30 ng/mL after discontinuation, with very low rates of perioperative bleeding or thrombotic events 5.

Common Pitfalls to Avoid

• Insufficient discontinuation time: Failing to account for renal function when determining discontinuation timing
• Unnecessary bridging: Unlike warfarin, apixaban does not require bridging therapy
• One-size-fits-all approach: Not adjusting discontinuation timing based on bleeding risk of the procedure
• Delayed resumption: Waiting too long to resume anticoagulation after adequate hemostasis is achieved, potentially increasing thrombotic risk

Remember that these recommendations are based on the patient's renal function and the bleeding risk of the procedure. Always confirm recent renal function tests before making decisions about apixaban discontinuation timing.