How long should Eliquis (apixaban) be held prior to surgery?

Perioperative Management of Apixaban (Eliquis) Before Surgery

Apixaban 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

Timing of Apixaban Discontinuation Based on Renal Function and Bleeding Risk

The timing of apixaban discontinuation depends on the patient's renal function and the bleeding risk associated with the planned procedure:

For Low Bleeding Risk Procedures:

• Normal or mild renal impairment (CrCl ≥50 mL/min): Stop apixaban 2 days before surgery (skip 2 doses) 2, 3
• Moderate renal impairment (CrCl 30-50 mL/min): Stop apixaban 3 days before surgery (skip 4 doses) 2, 3
• Severe renal impairment (CrCl 15-29 mL/min): Stop apixaban 3 days before surgery (skip 2 doses) 3

For High Bleeding Risk Procedures:

• Normal or mild renal impairment (CrCl ≥50 mL/min): Stop apixaban 3 days before surgery (skip 4 doses) 2, 3
• Moderate renal impairment (CrCl 30-50 mL/min): Stop apixaban 4 days before surgery (skip 6 doses) 2, 3
• Severe renal impairment (CrCl 15-29 mL/min): Stop apixaban 5 days before surgery 3

Clinical Evidence Supporting Recommendations

Recent clinical evidence supports these recommendations. The ADIOS study demonstrated that apixaban discontinuation for at least 48 hours before a procedure resulted in clinically insignificant anticoagulation levels in 94% of patients, with measured apixaban concentrations ≤30 ng/mL 4. This study was conducted in a naturalistic setting with a heterogeneous patient population, providing real-world validation of the recommended discontinuation periods.

Bridging Anticoagulation

Bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required 1. The American College of Chest Physicians recommends against preoperative bridging with heparin when interrupting direct oral anticoagulants like apixaban due to increased bleeding risk without additional thromboembolic protection 3.

Resumption of Apixaban After Surgery

Apixaban should be restarted after surgical or other procedures as soon as adequate hemostasis has been established 1:

• For low bleeding risk procedures: Resume 24 hours after the procedure
• For high bleeding risk procedures: Resume 48-72 hours after the procedure

Special Considerations

Cardiac Procedures

For patients with coronary stents requiring surgery, the American College of Cardiology/American Heart Association recommends:

• For bare-metal stents: Defer surgery for at least 6 weeks after placement
• For drug-eluting stents: Defer surgery for at least 6 months after placement 2

Common Pitfalls to Avoid

1. Insufficient discontinuation time before high-risk procedures
2. Failure to adjust discontinuation time based on renal function
3. Unnecessary bridging with heparin products, which increases bleeding risk
4. Premature resumption of apixaban before adequate hemostasis is achieved
5. Poor communication between healthcare providers regarding the timing of apixaban discontinuation and resumption

Conclusion

The evidence clearly supports discontinuing apixaban at least 48 hours before moderate to high bleeding risk procedures and at least 24 hours before low bleeding risk procedures, with adjustments based on renal function. Following these guidelines helps minimize perioperative bleeding complications while managing thromboembolic risk.