Is heparin prophylaxis safe for a patient on Eliquis (apixaban) after surgery?

Heparin Prophylaxis in Patients on Apixaban After Surgery

Heparin prophylaxis should NOT be used in patients already on apixaban (Eliquis) after surgery as it creates unnecessary duplicate anticoagulation and increases bleeding risk without additional thrombotic protection. 1

Understanding the Issue

When managing patients on apixaban who require thromboprophylaxis after surgery, it's important to recognize that:

• Apixaban is already an effective anticoagulant that provides thromboprophylaxis
• Adding heparin creates duplicate anticoagulation therapy
• The French Working Group on Perioperative Hemostasis (GIHP) specifically advises against overlapping anticoagulants 1

Appropriate Management Approach

For Patients Already on Apixaban

1. Perioperative Management of Apixaban:

   • For low bleeding risk procedures: Interrupt apixaban the night before surgery and resume ≥6 hours after procedure 1
   • For high bleeding risk procedures: Interrupt apixaban 3 days before surgery 1
   • For very high bleeding risk procedures (neurosurgery, neuraxial anesthesia): Longer interruption may be needed 1

2. Resumption of Anticoagulation:

   • Resume apixaban at least 6 hours after the end of surgery when hemostasis is achieved 1, 2
   • If twice daily regimen: Resume the evening of the same day
   • If once daily regimen: Resume the next morning or evening depending on usual schedule

3. When Thromboprophylaxis is Needed Before Apixaban Resumption:

   • If venous thromboprophylaxis is indicated before apixaban can be safely resumed, heparin may be administered at least 6 hours after surgery 1
   • Ensure there is NO OVERLAP between heparin and apixaban 1, 2

Important Considerations

Bleeding Risk

• Combining apixaban with heparin significantly increases bleeding risk without providing additional protection against thromboembolism 2, 3
• In the ARISTOTLE study, patients with diabetes on apixaban had higher bleeding rates (3% per year) compared to those without diabetes (1.9% per year) 3

Efficacy of Apixaban Alone

• Apixaban is highly effective for VTE prophylaxis with a 64% relative risk reduction compared to enoxaparin 2
• In the ADVANCE-3 trial for hip surgery, apixaban showed superior efficacy (1.4% vs 3.9% VTE incidence) compared to enoxaparin 2

Special Populations

• For elderly patients (≥80 years), those with low body weight (≤60 kg), or impaired renal function (creatinine ≥133 μmol/L), apixaban dosage may need adjustment to 2.5 mg BID 2, 3
• Monitor renal function before initiating therapy, especially important if CrCl is 30-50 mL/min 2

Common Pitfalls to Avoid

1. Duplicate Anticoagulation: Never combine full-dose apixaban with prophylactic heparin 1

2. Inadequate Interruption: Ensure proper timing of apixaban interruption before surgery based on bleeding risk 1

3. Premature Resumption: Don't restart apixaban before adequate hemostasis is achieved (minimum 6 hours post-procedure) 2

4. Failure to Adjust for Patient Factors: Consider dose adjustments for elderly patients, those with low body weight, or impaired renal function 2, 3

5. Overlooking Drug Interactions: Check for P-glycoprotein inhibitors and CYP3A4 inhibitors that may affect apixaban metabolism 2

By following these guidelines, you can ensure effective thromboprophylaxis while minimizing bleeding risks in patients on apixaban after surgery.