When should Eliquis (apixaban) be stopped prior to surgery?

Perioperative Management of Apixaban (Eliquis)

Apixaban (Eliquis) 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

Discontinuation Timeline Based on Bleeding Risk and Renal Function

Bleeding Risk Categories:

• Low bleeding risk procedures:

  • Discontinue apixaban 24 hours before procedure 2, 1
  • Examples: minor dental procedures, skin procedures, carpal tunnel surgery

• Moderate to high bleeding risk procedures:

  • Discontinue apixaban based on renal function 2:
    • Normal renal function: 48 hours before procedure
    • Moderate renal impairment: 72 hours before procedure
    • Severe renal impairment: 96 hours before procedure

Resumption of Apixaban After Surgery

• Low bleeding risk procedures:

  • Resume 24 hours after procedure when adequate hemostasis is established 2
  • Standard dose without reduction 2

• High bleeding risk procedures:

  • Resume 48-72 hours after procedure when adequate hemostasis is established 2

Important Clinical Considerations

• No bridging anticoagulation needed: Bridging with heparin or low molecular weight heparin during the perioperative interruption of apixaban is not recommended as it increases bleeding risk without additional benefit 2

• Monitoring requirements: For patients over 80 years old, careful monitoring is required due to increased bleeding risk, potentially reduced renal function affecting drug clearance, and higher stroke risk when off anticoagulation 2

• Drug levels: Recent research shows that apixaban discontinuation for at least 48 hours before a procedure resulted in clinically insignificant anticoagulation levels (≤30 ng/mL) in 94% of patients 3

• Emergency procedures: For emergent or urgent surgical procedures, laboratory testing to measure preoperative apixaban levels may help determine whether reversal agents (prothrombin complex concentrates or andexanet-α) are needed 4

Risks of Perioperative Management

• Bleeding risk: With appropriate perioperative DOAC management, major bleeding rates are typically 1-2% 4

• Thrombotic risk: Premature withdrawal of antiplatelet agents is associated with a 10% risk of vascular events 5, though standardized DOAC management protocols show thromboembolism rates of only 0.2-0.4% 4

• Post-procedure monitoring: Monitor vital signs frequently in the immediate post-procedure period and check the procedure site regularly for signs of bleeding 2

By following these evidence-based guidelines for perioperative management of apixaban, clinicians can minimize both bleeding and thrombotic risks while ensuring optimal patient outcomes.