Perioperative Management of Apixaban Before Surgery
For patients taking apixaban, the medication should be discontinued 2 days before surgery with low bleeding risk (skip 2 doses) and 3 days before surgery with high bleeding risk (skip 4 doses) in patients with normal renal function. 1, 2, 3
Discontinuation Timeline Based on Bleeding Risk and Renal Function
Normal or Mild Renal Impairment (CrCl ≥50 mL/min)
- Low bleeding risk procedures: Last dose 2 days before surgery (skip 2 doses)
- High bleeding risk procedures: Last dose 3 days before surgery (skip 4 doses)
Moderate Renal Impairment (CrCl 30-50 mL/min)
- Low bleeding risk procedures: Last dose 3 days before surgery (skip 4 doses)
- High bleeding risk procedures: Last dose 4 days before surgery (skip 6 doses)
Severe Renal Impairment (CrCl 15-29.9 mL/min)
- All procedures: Last dose 5 days before surgery
Bleeding Risk Assessment
Low Bleeding Risk Procedures
- Diagnostic endoscopy with or without biopsy
- Minor dental procedures
- Cataract surgery
- Minor dermatologic procedures
High Bleeding Risk Procedures
- Major surgery (cardiac, orthopedic, neurosurgical)
- Spinal or epidural anesthesia
- Endoscopic procedures with polypectomy
- Thoracentesis (especially large volume or difficult anatomy)
- Liver or kidney biopsy
Evidence Supporting Recommendations
The recommended discontinuation times are based on apixaban's half-life of 7-8 hours 1. A prospective cohort study (ADIOS) demonstrated that apixaban discontinuation for at least 48 hours before procedures resulted in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) 4. This supports the recommendation for a 2-day discontinuation period for low bleeding risk procedures.
For high bleeding risk procedures, the FDA label specifically states that apixaban should be discontinued at least 48 hours prior to procedures with moderate or high risk of significant bleeding 3. However, guidelines recommend a more conservative approach of 3 days (skipping 4 doses) for high bleeding risk procedures to ensure minimal residual anticoagulant effect 1, 2.
Resumption After Surgery
- Low bleeding risk procedures: Resume apixaban 24 hours after surgery
- High bleeding risk procedures: Resume 48-72 hours after surgery when adequate hemostasis is established
Common Pitfalls to Avoid
- Insufficient discontinuation time: Failing to account for renal function when determining discontinuation timeline
- Unnecessary bridging: Bridging with heparin or LMWH is generally not recommended when interrupting apixaban 2
- Premature resumption: Restarting apixaban too soon after high bleeding risk procedures
- Failure to communicate: Ensure clear communication between all healthcare providers about the perioperative anticoagulation plan
Special Considerations
For patients with very high thrombotic risk (recent VTE or stroke within 3 months, mechanical heart valve), consider consultation with a hematologist or cardiologist for individualized management.
In emergency situations requiring urgent surgery in patients on apixaban, prothrombin complex concentrate (PCC) may be considered for reversal 5. A retrospective study showed that PCC administration before urgent surgery in patients on apixaban resulted in acceptable hemostasis with bleeding reported in only 5% of patients 5.