How long should Eliquis (apixaban) be stopped before cataract surgery?

Perioperative Management of Apixaban (Eliquis) for Cataract Surgery

For patients taking apixaban (Eliquis) who require cataract surgery, apixaban can be safely continued throughout the perioperative period without interruption. 1, 2

Classification of Cataract Surgery Bleeding Risk

Cataract surgery is classified as a minimal-bleed-risk procedure with a 30-day risk of major bleeding of approximately 0% 1. This classification places it in the same category as:

• Minor dermatologic procedures
• Pacemaker or cardioverter-defibrillator implantation
• Minor dental procedures

Evidence-Based Recommendations

Direct Oral Anticoagulant (DOAC) Management

• The 2022 American College of Chest Physicians (ACCP) guidelines specifically list ophthalmologic (cataract) procedures as minimal-bleed-risk surgeries where anticoagulation can be continued 1
• For minimal-bleed-risk procedures, DOACs may be continued without interruption 1
• Local hemostasis techniques used during cataract surgery are typically sufficient to manage any minor bleeding 2

Specific Apixaban Considerations

• According to the FDA label, apixaban should be discontinued at least 24 hours prior to procedures with a low risk of bleeding 3
• However, more recent and specific guidelines from ACCP classify cataract surgery as minimal-bleed-risk (even lower than low-risk), supporting continuation without interruption 1

Practical Management Algorithm

1. Preoperative Assessment:

   • Confirm the patient is taking apixaban for an appropriate indication (atrial fibrillation, DVT/PE treatment or prevention)
   • Verify the current dosage (typically 5mg twice daily or 2.5mg twice daily)

2. Day Before Surgery:

   • Continue regular apixaban dosing schedule
   • No laboratory monitoring required

3. Day of Surgery:

   • Take morning dose of apixaban as scheduled
   • Option: If surgeon preference or individual patient factors suggest higher bleeding risk, consider timing the procedure at trough levels (just before the next scheduled dose) 2

4. Postoperative Management:

   • Resume or continue regular apixaban dosing schedule
   • No bridging anticoagulation required

Important Considerations

Benefits of Continuation

• Eliminates the risk of thromboembolism associated with interruption of anticoagulation
• Simplifies perioperative management
• Avoids the need for bridging anticoagulation

Anesthesia Considerations

• Topical or intracameral anesthesia is preferred over injectable anesthesia for patients on anticoagulants 4
• Avoid retrobulbar or peribulbar blocks if possible, as these carry higher bleeding risk

Special Situations

• For patients with extremely high bleeding risk factors (e.g., history of intraocular bleeding), individual assessment may be warranted
• If there are significant concerns about bleeding risk, consider consulting with the patient's cardiologist or hematologist before making any changes to the anticoagulation regimen

Potential Pitfalls to Avoid

1. Unnecessary discontinuation: Stopping apixaban before cataract surgery creates an unnecessary risk of thromboembolism without providing significant benefit in terms of bleeding risk reduction 2, 4

2. Inappropriate bridging: The rapid offset and onset of action of DOACs like apixaban obviates the need for heparin bridging in the perioperative setting 1

3. Delayed resumption: Apixaban should be resumed as soon as adequate hemostasis is achieved, typically the same day as surgery 3

4. Confusing guidelines: While older guidelines or those for higher-risk procedures recommend interruption, the most recent evidence supports continuation for cataract surgery specifically 1, 2

By following these evidence-based recommendations, clinicians can minimize both bleeding and thrombotic risks for patients undergoing cataract surgery while on apixaban therapy.