Timing of Apixaban (Eliquis) Discontinuation Before Procedures
For high bleeding risk procedures, apixaban should be discontinued at least 48 hours prior to the procedure, while for low bleeding risk procedures, omitting the morning dose on the day of the procedure is sufficient. 1, 2
Procedure-Based Discontinuation Timeline
High Bleeding Risk Procedures
- Last dose timing: At least 48 hours before procedure 1, 2
- Examples: Neuraxial procedures, major surgery, cardiac/intracranial/spinal surgery, major organ surgery, colonoscopy with polypectomy 2
- Special considerations: For patients with renal impairment (CrCl 30-50 mL/min), extend to 72 hours before procedure 3
Low-to-Moderate Bleeding Risk Procedures
- Last dose timing: Omit morning dose on day of procedure 2
- Examples: Diagnostic endoscopy, colonoscopy with biopsy, coronary angiography 2
- Special considerations: For once daily regimen, last dose should be taken two days before procedure 2
Minimal Bleeding Risk Procedures
- Recommendation: May continue apixaban 2
- Examples: Minor dermatologic procedures, cataract surgery, dental cleanings 2
Renal Function Considerations
Renal function significantly impacts apixaban clearance and should guide discontinuation timing:
| Renal Function | CrCl (mL/min) | High Bleeding Risk | Low-Moderate Bleeding Risk |
|---|---|---|---|
| Normal | ≥50 | 48 hours | Omit morning dose |
| Moderate | 30-50 | 72 hours | 24 hours |
| Severe | <30 | Consult hematology | Consult hematology |
Resumption of Apixaban
- Resume once adequate hemostasis is achieved 1
- For low bleeding risk procedures: Resume same evening or next morning 2
- For high bleeding risk procedures: Resume 24-72 hours after procedure 3
- No bridging anticoagulation is typically required 2, 3
Important Considerations
- Thrombotic risk assessment: Balance bleeding risk against thrombotic risk, especially in patients with recent VTE or high CHADS₂ score 3
- Procedure postponement: Consider postponing elective procedures if discontinuation poses significant thrombotic risk 2
- Laboratory monitoring: Not routinely required when following recommended interruption periods 3
- Post-procedure monitoring: Watch for signs of bleeding, especially after high-risk procedures 3
Special Situations
- Neuraxial procedures: Require complete absence of anticoagulant effect (48-72 hours) due to risk of epidural hematoma 1
- Concomitant medications: Patients on antiplatelet agents or NSAIDs have increased bleeding risk 3
- Emergency procedures: For urgent procedures where apixaban cannot be discontinued, specific reversal agents may be considered 4
The ADIOS study demonstrated that apixaban discontinuation for at least 48 hours before procedures resulted in clinically insignificant anticoagulation levels in most patients, with very low rates of perioperative thromboembolism and bleeding 5.