How long should Eliquis (apixaban) be stopped before a surgical procedure?

Perioperative Management of Apixaban (Eliquis) Before Surgical Procedures

For most patients on apixaban (Eliquis), discontinuation should occur 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

Timing of Apixaban Discontinuation Based on Bleeding Risk and Renal Function

High Bleeding Risk Procedures

• Normal or mild renal impairment (CrCl ≥50 mL/min): Stop apixaban 3 days before surgery (skip 4 doses) 2
• Moderate renal impairment (CrCl 30-50 mL/min): Stop apixaban 4 days before surgery (skip 6 doses) 2

Low-to-Moderate Bleeding Risk Procedures

• Normal or mild renal impairment (CrCl ≥50 mL/min): Stop apixaban 2 days before surgery (skip 2 doses) 2
• Moderate renal impairment (CrCl 30-50 mL/min): Stop apixaban 3 days before surgery (skip 4 doses) 2

Minimal Bleeding Risk Procedures

• Continue apixaban for procedures such as:
  • Minor dental procedures
  • Minor dermatologic procedures
  • Cataract surgery
  • Pacemaker or cardioverter-defibrillator implantation 2

Procedure-Specific Bleeding Risk Classification

High Bleeding Risk (30-day risk of major bleed >2%)

• Major orthopedic surgery
• Cardiac, intracranial, or spinal surgery
• Major cancer surgery
• Urological procedures (prostate/bladder surgery)
• Surgery in highly vascular organs (kidneys, liver, spleen)
• Any major operation (procedure duration >45 min)
• Neuraxial anesthesia/epidural injections 2

Low-to-Moderate Bleeding Risk (30-day risk of major bleed 0-2%)

• Arthroscopy
• Cutaneous/lymph node biopsies
• Coronary angiography
• GI endoscopy with biopsy
• Colonoscopy with biopsy
• Abdominal hysterectomy
• Laparoscopic cholecystectomy 2

Minimal Bleeding Risk (30-day risk of major bleed ~0%)

• Minor dermatologic procedures
• Ophthalmologic (cataract) procedures
• Minor dental procedures
• Pacemaker or cardioverter-defibrillator device implantation 2

Evidence Supporting Recommendations

The FDA label for apixaban specifically states that it should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding, and at least 24 hours prior to procedures with low risk of bleeding 1. This recommendation is supported by clinical evidence showing that discontinuation of apixaban for at least 48 hours before a procedure resulted in clinically insignificant anticoagulation levels 3.

The 2022 American College of Chest Physicians guidelines provide specific recommendations for different DOACs, including apixaban, based on procedure bleeding risk and patient renal function 2. These recommendations are more detailed than the FDA label and account for the pharmacokinetic properties of apixaban.

Resuming Apixaban After Surgery

• Low bleeding risk procedures: Resume apixaban at least 24 hours after the procedure 2
• High bleeding risk procedures: Resume apixaban 48-72 hours after the procedure 2, 4
• No bridging anticoagulation is generally required during the perioperative period due to the rapid onset and offset of action of apixaban 2

Special Considerations

1. Neuraxial Anesthesia: Particular caution is needed when neuraxial anesthesia is planned. Epidural or spinal hematomas may occur in patients receiving apixaban who undergo spinal puncture, potentially resulting in long-term or permanent paralysis 1. Ensure minimal to no residual anticoagulant effect at the time of procedure (4-5 drug half-lives of interruption) 4.

2. Emergency Surgery: For urgent procedures, consider measuring apixaban levels if available. When apixaban levels are elevated, anticoagulant reversal agents may be appropriate 5.

3. Bridging: Unlike warfarin, bridging with heparin or LMWH is typically not necessary with apixaban due to its predictable pharmacokinetics and short half-life 2.

4. Thromboembolic Risk: The perioperative risk of thromboembolism with this management approach is very low (0.2-0.4%) 5.

Practical Approach

1. Assess the bleeding risk of the planned procedure
2. Evaluate patient's renal function
3. Determine the appropriate timing for apixaban discontinuation based on these factors
4. Plan for appropriate timing of postoperative apixaban resumption
5. No bridging anticoagulation is typically needed

This approach has been shown to be safe and effective, with studies demonstrating low rates of perioperative thromboembolism and major bleeding when following these protocols 3, 5.