When to restart Eliquis (apixaban) for Deep Vein Thrombosis (DVT) prophylaxis?

Restarting Eliquis for DVT Prophylaxis

Apixaban (Eliquis) should be restarted as soon as adequate hemostasis has been established after surgery or invasive procedures, typically within 24-48 hours for low bleeding risk procedures and after hemostasis is confirmed for higher risk procedures. 1

Assessment of Bleeding vs. Thrombotic Risk

When determining the optimal timing for restarting anticoagulation, clinicians must balance the dual therapeutic aims of preventing thrombotic events while minimizing rebleeding risk.

Factors to Consider Before Restarting:

1. Bleeding Risk Assessment:

   • Was the bleeding at a critical site? (intracranial, spinal, retroperitoneal)
   • Is the patient hemodynamically stable?
   • Has the source of bleeding been identified and controlled?
   • Is the patient at high risk of rebleeding?

2. Thrombotic Risk Assessment:

   • Original indication for anticoagulation (provoked vs. unprovoked DVT)
   • Time since initial DVT diagnosis
   • Patient-specific risk factors for recurrent thrombosis

Timing of Anticoagulation Reinitiation

For Low Bleeding Risk Procedures:

• Restart Eliquis 24 hours after procedure once hemostasis is adequate 1
• No bridging anticoagulation is generally required

For Moderate to High Bleeding Risk Procedures:

• Restart Eliquis 48-72 hours after procedure once hemostasis is adequate 1
• For patients at high thrombotic risk who cannot immediately restart full anticoagulation, consider:
  • Prophylactic doses of parenteral anticoagulants initially
  • Unfractionated heparin (due to short half-life and availability of reversal agent) 2

Special Considerations:

• If bleeding occurred at a critical site: Delay restart of anticoagulation until specialists (neurosurgeon, gastroenterologist) confirm it's safe to resume 2
• If source of bleeding has not been identified: Delay restart until source is identified and controlled
• If patient has high thrombotic risk but also high bleeding risk: Consider temporary prophylactic doses with close monitoring 2

Dosing When Restarting

For DVT prophylaxis with Eliquis (apixaban):

• Standard prophylactic dose: 2.5 mg twice daily 1
• For treatment of DVT/PE: Initial 10 mg twice daily for 7 days, then 5 mg twice daily 1
• For reduction in risk of recurrent DVT/PE: 2.5 mg twice daily after at least 6 months of treatment 1

Common Pitfalls to Avoid

1. Premature restart of anticoagulation before adequate hemostasis is achieved
2. Excessive delay in restarting anticoagulation in patients at high thrombotic risk
3. Failure to reassess the patient's risk factors for both bleeding and thrombosis
4. Not considering drug interactions that may increase anticoagulant levels (e.g., medications that inhibit CYP3A4 or P-glycoprotein) 1
5. Overlooking patient preferences and not discussing the risks and benefits of restarting anticoagulation

Follow-up and Monitoring

• All patients should be monitored for signs of recurrent bleeding or thrombosis
• Patients should be educated about warning signs of bleeding or thrombosis
• Reassess the need for continued anticoagulation at least annually 2
• Consider periodic laboratory monitoring in patients with renal impairment or other risk factors for complications

Remember that the decision to restart anticoagulation should involve a multidisciplinary care team when possible, especially for complex cases with competing risks of thrombosis and bleeding 2.