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

Timing of Eliquis (Apixaban) Discontinuation Before Surgery

Eliquis (apixaban) should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate to high bleeding risk, and at least 24 hours prior to procedures with low bleeding risk. 1

Discontinuation Protocol Based on Bleeding Risk

The timing of apixaban discontinuation depends on the bleeding risk associated with the surgical procedure:

High Bleeding Risk Procedures

• Stop apixaban: 48 hours before surgery
• Examples: major cancer surgery, joint replacement, neurosurgery
• For patients with renal impairment, consider longer discontinuation periods

Low to Moderate Bleeding Risk Procedures

• Stop apixaban: 24 hours before surgery
• Examples: cholecystectomy, inguinal hernia repair
• Timing allows for adequate clearance of the drug 2

Minimal Bleeding Risk Procedures

• Option to continue apixaban without interruption
• Examples: minor dental procedures including tooth extractions 3
• Consider using local hemostatic measures such as tranexamic acid mouthwash when continuing apixaban 3

Evidence Supporting These Recommendations

The FDA drug label explicitly states that apixaban should be discontinued at least 48 hours prior to elective surgery with moderate or high bleeding risk, and at least 24 hours prior to procedures with low bleeding risk 1. This recommendation is supported by clinical research showing that apixaban discontinuation for at least 48 hours before a procedure resulted in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) 4.

Special Considerations

Renal Function

• Apixaban has approximately 27% renal clearance 5
• Patients with impaired renal function may require longer discontinuation periods, though specific guidance is limited

Age and Weight

• Patients over 80 years require careful monitoring due to increased bleeding risk 3
• Standard dose reduction criteria (age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) should be considered when restarting apixaban 3

Bridging Anticoagulation

• Bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required 1
• Avoid overlapping anticoagulants as it increases bleeding risk without additional benefit 3

Resumption Protocol

• Resume apixaban as soon as adequate hemostasis has been established 1
• For standard procedures, resume at least 6 hours after the procedure if there is no ongoing bleeding 3
• For procedures with low bleeding risk: resume 24 hours after procedure
• For procedures with high bleeding risk: resume 48-72 hours after procedure 3

Emergency Surgery Considerations

For patients requiring emergency surgery:

• Laboratory testing to measure preoperative apixaban levels may be useful
• Consider reversal agents (prothrombin complex concentrates) if surgery cannot be delayed 2, 6
• The risk of major bleeding can be as high as 23% in emergency surgeries with insufficient drug clearance 2

Common Pitfalls to Avoid

1. Insufficient discontinuation time: Ensure adequate time based on procedure risk
2. Premature resumption: Verify adequate hemostasis before restarting
3. Overlooking drug interactions: Patients on P-gp and CYP3A4 inhibitors may have prolonged apixaban effects
4. Ignoring renal function: Patients with impaired renal function may need longer discontinuation periods
5. Spinal/epidural anesthesia: Should be strongly avoided in patients with possible residual apixaban concentration 3