Do you bridge apixaban (a direct oral anticoagulant) for surgery?

Perioperative Management of Apixaban for Surgery

For patients taking apixaban who require surgery, discontinue apixaban 2 days before high bleeding risk procedures and 1 day before low bleeding risk procedures, with no need for bridging therapy in most cases.

Timing of Apixaban Discontinuation

The timing of apixaban discontinuation depends primarily on the bleeding risk of the procedure:

Low to Moderate Bleeding Risk Procedures:

• Discontinue apixaban 24 hours before the procedure (1 full day) 1
• This provides approximately 30-36 hours of interruption (about three half-lives) 1
• Examples: minor dental procedures, skin procedures, cholecystectomy, hernia repair

High Bleeding Risk Procedures:

• Discontinue apixaban 48 hours before the procedure (2 full days) 1, 2
• Examples: major cancer surgery, joint replacement, neurosurgery, cardiac surgery

Very High Bleeding Risk Procedures:

• For neuraxial anesthesia or intracranial neurosurgery, consider longer interruption periods 1
• For spinal/epidural anesthesia, a longer interruption time up to 5 days may be needed 1

Special Considerations

Renal Function:

• Unlike dabigatran (which requires 4-5 days discontinuation with impaired renal function), apixaban's dual elimination pathway (only 25% renal) allows for standard discontinuation timing in most patients 1
• However, patients with severely impaired renal function (CrCl <30 mL/min) may require longer discontinuation periods 1

Drug Interactions:

• Patients taking CYP3A4 or P-glycoprotein inhibitors may need longer discontinuation periods due to delayed drug clearance 1
• These include medications like ketoconazole, itraconazole, and ritonavir 2

Laboratory Testing:

• Routine laboratory testing before surgery is not necessary with standardized discontinuation protocols 3
• Consider measuring apixaban levels only for urgent surgeries (within 24 hours) 1
• Most patients (94%) achieve clinically insignificant anticoagulation levels (<30 ng/mL) when apixaban is held for at least 48 hours 4

Resumption of Apixaban After Surgery

The timing of apixaban resumption depends on surgical hemostasis and bleeding risk:

Low Bleeding Risk Procedures:

• Resume apixaban 24 hours after the procedure 1
• For minimal bleeding risk procedures (dental, dermatologic), can resume the same evening 1

High Bleeding Risk Procedures:

• Resume apixaban 48-72 hours after the procedure 1
• Consider using prophylactic doses of heparin or LMWH starting 6-12 hours post-procedure until apixaban is resumed 1

Bridging Therapy

Bridging with heparin or LMWH is generally NOT recommended for patients on apixaban 1, 3. This differs from warfarin management, where bridging may be considered for high thrombotic risk patients.

Rationale for No Bridging:

1. Apixaban has a shorter half-life than warfarin
2. Studies show bridging increases bleeding risk without reducing thrombotic events 1
3. Rapid onset of action when resumed (2-4 hours) 3

Exception:

• Consider bridging only for patients at very high thrombotic risk who cannot tolerate oral medications postoperatively 1

Common Pitfalls to Avoid

1. Unnecessary bridging: Bridging therapy increases bleeding risk without clear benefit for most patients on apixaban 1

2. Inadequate discontinuation time: Failing to account for renal function or drug interactions can lead to elevated perioperative apixaban levels 1

3. Too early resumption: Resuming full-dose apixaban too soon after major surgery increases bleeding risk 1

4. One-size-fits-all approach: Failing to adjust timing based on procedure bleeding risk 1

5. Overlooking drug interactions: P-glycoprotein and CYP3A4 inhibitors can increase apixaban levels 2

By following these evidence-based guidelines for perioperative management of apixaban, clinicians can minimize both bleeding and thrombotic complications in surgical patients.