Perioperative Management of Eliquis (Apixaban)
For patients with normal renal function, Eliquis (apixaban) should be discontinued at least 48 hours prior to procedures with moderate or high risk of bleeding, and at least 24 hours prior to procedures with low risk of bleeding. 1
Discontinuation Timeline Based on Procedure Risk and Renal Function
High Bleeding Risk Procedures
- Normal renal function (CrCl ≥50 mL/min): Stop 3 days before surgery (skip 4 doses) or 2 days before surgery (skip 2 doses) 2
- Moderate renal impairment (CrCl 30-50 mL/min): Stop 4 days before surgery (skip 6 doses) or 3 days before surgery (skip 4 doses) 2
- Severe renal impairment (CrCl 15-29 mL/min): Stop 5 days before surgery 2
Low Bleeding Risk Procedures
- Stop at least 24 hours before procedure 1
- For minor dental procedures, apixaban can be continued without interruption 2
Procedure Risk Stratification
High Bleeding Risk Procedures
- Endoscopic polypectomy
- ERCP with sphincterotomy
- Endoscopic mucosal resection or submucosal dissection
- Endoscopic therapy of varices
- Neuraxial procedures (including epidural injections)
- Major surgeries 3
Low Bleeding Risk Procedures
- Diagnostic endoscopy with or without biopsy
- Biliary or pancreatic stenting
- Minor dental procedures 3, 2
Resumption of Apixaban
- Resume when adequate hemostasis is established, typically at least 6 hours after the end of the procedure 2
- For high bleeding risk procedures, consider delaying resumption for 24-48 hours 2
- For neuraxial procedures, wait at least 24 hours before resuming 2
Important Considerations
- Check renal function: The elimination of apixaban is affected by renal function, which determines the appropriate discontinuation timeline 2
- Avoid bridging: The French Working Group on Perioperative Hemostasis and the American College of Chest Physicians recommend against preoperative bridging with heparin when interrupting DOACs like apixaban, as it increases bleeding risk without providing additional thromboembolic protection 2
- Thrombotic risk assessment: Consider the patient's underlying condition (atrial fibrillation, mechanical heart valve, history of VTE) to determine thromboembolic risk 2
Common Pitfalls to Avoid
- Insufficient discontinuation time: Ensure adequate time off apixaban before surgery based on renal function
- Premature resumption: Resuming full-dose apixaban too soon after surgery can increase bleeding risk
- Failure to adjust for renal function: Patients with impaired renal function require longer discontinuation periods
- Inadequate communication: Ensure coordination between surgeon, anesthesiologist, and prescribing physician regarding the perioperative anticoagulation plan 2
The FDA label for apixaban explicitly 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 1. This recommendation is supported by clinical evidence showing that discontinuation for at least 48 hours results in clinically insignificant anticoagulation levels prior to surgical procedures 4.