Perioperative Management of Apixaban (Eliquis)
Apixaban can be safely stopped without tapering and should be discontinued 24-48 hours before procedures with low bleeding risk and 48-72 hours before procedures with high bleeding risk, depending on renal function. 1
Discontinuation Protocol for Apixaban
Apixaban, as a direct oral anticoagulant (DOAC), has a predictable pharmacokinetic profile with a relatively short half-life, making tapering unnecessary. The European Society of Cardiology and other guidelines recommend the following discontinuation timeline based on bleeding risk and renal function:
Based on Renal Function:
- Normal renal function: Discontinue 48 hours before procedure
- Moderate renal impairment: Discontinue 72 hours before procedure
- Severe renal impairment: Discontinue 96 hours before procedure 1
Based on Procedure Bleeding Risk:
- Low bleeding risk procedures: Discontinue 24 hours before procedure
- High bleeding risk procedures: Discontinue 48-72 hours before procedure 1
Resumption Protocol
Resumption of apixaban should occur only after adequate hemostasis has been established:
- Low bleeding risk procedures: Resume 24 hours after procedure
- High bleeding risk procedures: Resume 48-72 hours after procedure 1
Important Clinical Considerations
Monitoring After Discontinuation
- Unlike medications that require tapering (such as thrombopoietin receptor agonists in immune thrombocytopenia 2), apixaban has a predictable clearance and does not require gradual dose reduction.
- Monitor for signs of thrombotic events during the perioperative period when anticoagulation is interrupted.
Risk Assessment
- For patients at very high thrombotic risk, hematology consultation may be warranted to develop an individualized approach 1.
- Bridging with heparin or low molecular weight heparin is generally not recommended during the perioperative interruption of apixaban, as it increases bleeding risk without additional benefit 1.
Post-Procedure Care
- Monitor vital signs (pulse, blood pressure) regularly after resuming apixaban
- Check the procedure site for signs of bleeding
- Avoid strenuous physical activities for at least 48 hours after procedures 1
Management of Bleeding Complications
If bleeding occurs after resuming apixaban:
- For minor bleeding: Observation and supportive care
- For significant bleeding: Volume resuscitation, blood transfusion, or angiographic embolization
- For severe ongoing bleeding: Surgical intervention or reversal agents (andexanet alfa or prothrombin complex concentrate) may be necessary 1
Clinical Pearls
- Unlike medications such as opioids 2 or certain biologics 2 that require tapering to minimize withdrawal symptoms or disease exacerbation, apixaban has a predictable clearance and does not require gradual dose reduction.
- The pharmacokinetic profile of apixaban allows for direct discontinuation without tapering, with a predictable anticoagulant effect that diminishes as the drug is cleared 3, 4.
- Apixaban's relatively short half-life (approximately 12 hours) enables straightforward discontinuation and resumption protocols 5.
Remember that the decision to discontinue apixaban should always be made in consultation with the prescribing physician, especially for patients with high thrombotic risk.