How long should apixaban (apixaban) be stopped before surgery in a patient with normal renal function?

Perioperative Management of Apixaban Before Surgery

For patients with normal renal function, apixaban should be discontinued 1 day before low-to-moderate bleeding risk procedures and 2 days before high bleeding risk procedures. 1

Bleeding Risk Stratification

The timing of apixaban discontinuation depends primarily on the bleeding risk of the planned procedure:

High Bleeding Risk Procedures (stop apixaban 2 days before)

• Major surgeries lasting >45 minutes
• Neuraxial anesthesia
• Epidural injections
• Neurosurgical procedures
• Cardiac or vascular surgeries
• Major orthopedic surgeries

Low-to-Moderate Bleeding Risk Procedures (stop apixaban 1 day before)

• Arthroscopy
• Cutaneous/lymph node biopsies
• Coronary angiography (femoral approach)
• GI endoscopy with biopsy
• Colonoscopy with biopsy
• Abdominal surgeries (hysterectomy, cholecystectomy, hernia repair)
• Bronchoscopy with biopsy

Minimal Bleeding Risk Procedures (no need to stop apixaban)

• Minor dermatologic procedures
• Cataract surgery
• Minor dental procedures including extractions
• Pacemaker or defibrillator implantation
• Coronary angiography (radial approach) 1, 2

Specific Timing Recommendations

The FDA label for apixaban states that it should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of significant bleeding, and at least 24 hours prior to procedures with low bleeding risk 3. However, the most recent ACCP guidelines provide more specific recommendations based on bleeding risk stratification.

For patients with normal renal function:

• Low-to-moderate bleeding risk procedures: Last dose of apixaban should be taken the day before the procedure (i.e., skip one day, which equals approximately 2-3 half-lives)
• High bleeding risk procedures: Last dose of apixaban should be taken 2 days before the procedure (i.e., skip two days, which equals approximately 4-5 half-lives) 1

Important Clinical Considerations

• No bridging anticoagulation needed: The rapid offset and onset of action of apixaban eliminates the need for bridging with heparin or LMWH in the perioperative setting 1

• Resumption timing: Apixaban should be resumed:

  • At least 24 hours after low-to-moderate bleeding risk procedures
  • 48-72 hours after high bleeding risk procedures 1

• Peak effect timing: Apixaban reaches peak effect 1-3 hours after intake, requiring cautious administration after surgery 1

• Renal function impact: Unlike dabigatran, apixaban discontinuation timing does not need to be extended for patients with impaired renal function, as only about 27% of apixaban is eliminated via renal excretion 4

• Half-life considerations: Apixaban has a half-life of approximately 12 hours, which supports the recommended discontinuation timing 4

Evidence Quality

The 2022 American College of Chest Physicians guidelines provide the most current and authoritative recommendations for perioperative management of apixaban 1. These recommendations are supported by clinical research showing that discontinuing apixaban for at least 48 hours before procedures results in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) 5.

Common Pitfalls to Avoid

1. Unnecessarily prolonged discontinuation: Stopping apixaban for longer than recommended increases thrombotic risk without additional benefit

2. Inadequate discontinuation time: Not allowing sufficient time before high bleeding risk procedures can lead to significant perioperative bleeding

3. Inappropriate bridging: Using heparin bridging with apixaban increases bleeding risk without additional benefit 2

4. Premature resumption: Restarting apixaban too soon after surgery (especially within 24 hours) can increase bleeding risk due to its rapid onset of action

5. Failure to adjust for procedure timing: Morning procedures may require different timing than afternoon procedures to ensure appropriate drug clearance

By following these evidence-based recommendations for perioperative management of apixaban, clinicians can effectively balance the risks of thromboembolism and bleeding in patients undergoing surgical procedures.