What anticoagulant can a patient with atrial fibrillation (afib) be switched to from Eliquis (apixaban) due to pending surgery for a left hip fracture?

Anticoagulation Management for Atrial Fibrillation Patient with Pending Hip Fracture Surgery

For a patient with atrial fibrillation who cannot take Eliquis (apixaban) due to pending left hip fracture surgery, low-molecular-weight heparin (LMWH) should be used as a bridging therapy until surgery can be performed.

Perioperative Anticoagulation Management Algorithm

Step 1: Discontinue Apixaban

• Stop apixaban at least 48 hours before surgery for hip fracture, as this is considered a procedure with moderate to high bleeding risk 1
• For patients with normal renal function, this timing is sufficient to minimize bleeding risk during surgery

Step 2: Bridging Therapy Selection

• Use LMWH (such as enoxaparin) as the bridging agent for patients with non-valvular atrial fibrillation 2
• No bridging is typically needed when stopping apixaban, but for urgent hip fracture surgery where the patient cannot wait the full 48 hours, LMWH provides flexibility

Step 3: Dosing Considerations

• For therapeutic anticoagulation: Enoxaparin 1 mg/kg subcutaneously twice daily
• Adjust dose based on renal function and weight
• Last dose of LMWH should be given 24 hours before surgery, using half the therapeutic dose 2

Step 4: Post-Operative Management

• Resume thromboprophylaxis with LMWH at least 6 hours after surgery when hemostasis is achieved 2
• For patients with high thrombotic risk, therapeutic anticoagulation can usually be resumed between 24-72 hours postoperatively 2
• The first therapeutic dose should be administered 12 hours after the last prophylactic dose 2

Evidence-Based Rationale

The 2019 AHA/ACC/HRS guidelines recommend that for patients with AF without mechanical heart valves who require interruption of anticoagulation for procedures, decisions about bridging therapy should balance the risks of stroke and bleeding 2. While the BRIDGE trial showed that no bridging was non-inferior to bridging with LMWH for patients on warfarin, this patient's urgent hip fracture surgery presents a special circumstance.

For patients with high thrombotic risk, LMWH provides several advantages over unfractionated heparin:

• Longer half-life
• More predictable bioavailability (>90% after subcutaneous injection)
• Predictable clearance enabling once or twice-daily administration
• Predictable antithrombotic response based on body weight 2

A randomized controlled trial demonstrated that LMWH was safe and effective in preventing ischemic stroke in patients with acute AF, with no patients in the LMWH group developing stroke compared to 5 patients in the unfractionated heparin group 3.

Special Considerations

Reversal Options

• If emergency surgery is needed before the 48-hour window, andexanet alfa can be useful for the reversal of apixaban in the event of life-threatening or uncontrolled bleeding 2
• Monitor renal function postoperatively as changes may affect dosing of both apixaban and LMWH 2

Post-Surgical Anticoagulation

• Once adequate hemostasis is achieved after surgery, resume apixaban at the previous dose
• If epidural anesthesia was used, therapeutic anticoagulation must be administered with heparin to safely withdraw the catheter 2

Common Pitfalls to Avoid

1. Inadequate discontinuation time: Ensure full 48 hours off apixaban before major orthopedic surgery
2. Inappropriate bridging: Not all patients require bridging, but for urgent hip fracture surgery, LMWH provides flexibility
3. Resuming anticoagulation too early: Wait until adequate hemostasis is achieved post-surgery
4. Overlooking drug interactions: P-glycoprotein inhibitors and CYP3A4 inhibitors can increase bleeding risk with apixaban

By following this algorithm, you can effectively manage anticoagulation in your patient with atrial fibrillation undergoing hip fracture surgery while minimizing both thrombotic and bleeding risks.