When should apixaban (generic name: apixaban) be stopped prior to surgery in patients with normal or impaired renal function?

Perioperative Management of Apixaban

For patients taking apixaban, discontinuation should be 1 day before low-to-moderate-bleeding-risk procedures and 2 days before high-bleeding-risk procedures, regardless of renal function. 1

Timing of Apixaban Discontinuation Based on Procedure Bleeding Risk

High-Bleeding-Risk Procedures

• Stop apixaban 2 days before surgery (approximately 48 hours) 1
• Examples include:
  • Major surgeries lasting >45 minutes
  • Neuraxial anesthesia
  • Epidural injections
  • Neurosurgical procedures
  • Major cardiac, vascular, or abdominal surgeries

Low-to-Moderate-Bleeding-Risk Procedures

• Stop apixaban 1 day before surgery (approximately 24 hours) 1
• Examples include:
  • Arthroscopy
  • Cutaneous/lymph node biopsies
  • Foot/hand surgery
  • Coronary angiography
  • GI endoscopy with biopsy
  • Colonoscopy with biopsy
  • Abdominal hysterectomy
  • Laparoscopic cholecystectomy

Minimal-Bleeding-Risk Procedures

• No need to discontinue apixaban 2
• Examples include:
  • Minor dental procedures (extractions, restorations)
  • Cataract surgery
  • Minor dermatologic procedures

Special Considerations

Renal Function

Unlike dabigatran, which requires extended interruption in patients with impaired renal function, apixaban discontinuation timing does not need to be adjusted based on renal function 1. This is because apixaban has multiple elimination pathways with only approximately 27% of clearance occurring via renal excretion 3.

Bridging Anticoagulation

The rapid offset and onset of action of apixaban eliminates the need for bridging with short-acting anticoagulants such as unfractionated heparin or low molecular weight heparin in the perioperative setting 1.

Resumption of Apixaban After Surgery

The timing for resumption of apixaban depends on the bleeding risk of the procedure:

• Low-to-moderate-bleeding-risk procedures: Resume at least 24 hours after surgery 1
• High-bleeding-risk procedures: Resume 48-72 hours after surgery 1

It's important to note that apixaban has a rapid onset of action, with peak effect occurring 1-3 hours after intake, requiring cautious administration after surgery 1.

Evidence Quality and Practical Considerations

The recommendations from the 2022 American College of Chest Physicians (ACCP) guidelines provide the most current and authoritative guidance on perioperative management of apixaban 1. These recommendations are supported by clinical studies showing that discontinuation of apixaban for at least 48 hours before high-bleeding-risk procedures results in clinically insignificant anticoagulation levels 4.

A prospective observational study demonstrated that 94% of patients who discontinued apixaban at least 48 hours before surgery had apixaban concentrations ≤30 ng/mL, which is considered clinically insignificant for bleeding risk 4.

Common Pitfalls to Avoid

1. Insufficient discontinuation time: Not stopping apixaban early enough before high-bleeding-risk procedures can lead to increased perioperative bleeding.

2. Premature resumption: Restarting apixaban too soon after surgery (especially within the first few hours) can increase bleeding risk due to its rapid onset of action.

3. Unnecessary bridging: Using heparin bridging with apixaban is unnecessary and may increase bleeding risk 1.

4. Overlooking drug interactions: Strong dual inhibitors of CYP3A4 and P-gp can increase apixaban levels and may require longer discontinuation periods 5.

5. Failure to distinguish between procedure types: Not differentiating between high, moderate, and low bleeding risk procedures when planning apixaban interruption.