When should Eliquis (apixaban) be held before surgery to minimize bleeding risk in patients with impaired renal function?

Timing of Eliquis (Apixaban) Discontinuation Before Surgery in Patients with Impaired Renal Function

For patients with impaired renal function, Eliquis should be discontinued at least 24 hours before low bleeding risk procedures and at least 48 hours before high bleeding risk procedures, with longer discontinuation times (36 hours) for patients with severe renal impairment (CrCl 15-29 mL/min) undergoing low bleeding risk procedures. 1

Discontinuation Timeline Based on Renal Function and Bleeding Risk

Low Bleeding Risk Procedures

• Normal renal function (CrCl ≥80 mL/min): Stop Eliquis ≥24 hours before procedure
• Moderate renal impairment (CrCl 50-79 mL/min): Stop Eliquis ≥24 hours before procedure
• Moderate to severe renal impairment (CrCl 30-49 mL/min): Stop Eliquis ≥24 hours before procedure
• Severe renal impairment (CrCl 15-29 mL/min): Stop Eliquis ≥36 hours before procedure 1

High Bleeding Risk Procedures

• All renal function categories (CrCl ≥15 mL/min): Stop Eliquis ≥48 hours before procedure 1, 2

Procedure Bleeding Risk Classification

Low Bleeding Risk Procedures:

• Minor dental procedures (including 1-3 tooth extractions)
• Cataract or glaucoma surgery
• Endoscopy without biopsy
• Superficial surgery (small dermatologic excisions)
• Pacemaker or defibrillator implantation 1, 3

High Bleeding Risk Procedures:

• Major orthopedic surgery
• Extensive oral surgery
• Major cancer surgery
• Neurosurgery
• Complex cardiovascular procedures 1, 4

Important Considerations

No Bridging Anticoagulation

• Bridging with LMWH or heparin is not recommended when stopping Eliquis before surgery
• Mixing two anticoagulants increases bleeding risk without additional benefit 1, 3

Renal Function Assessment

• Accurately assess renal function before determining discontinuation timing
• Creatinine clearance should be calculated using the Cockcroft-Gault equation 5
• Patients with impaired renal function have shown the greatest reduction in major bleeding with apixaban compared to warfarin 5

Resumption After Surgery

• For low bleeding risk procedures: Resume Eliquis ≥24 hours after procedure
• For high bleeding risk procedures: Resume Eliquis 48-72 hours after procedure 1, 3
• Ensure adequate hemostasis has been established before restarting 2

Special Populations

• Elderly patients (≥80 years) require careful monitoring due to potentially reduced renal function and increased bleeding risk 3
• For patients on reduced dose Eliquis (2.5 mg twice daily), the same discontinuation timing applies 2

Clinical Evidence

Recent clinical data from the ADIOS study showed that discontinuing apixaban for at least 48 hours before surgery resulted in clinically insignificant anticoagulation levels in most patients (94% had apixaban concentrations ≤30 ng/mL) 6. This supports the recommended discontinuation times in current guidelines.

Common Pitfalls to Avoid

• Failing to account for renal function when determining discontinuation timing
• Unnecessary bridging with LMWH, which increases bleeding risk
• Resuming anticoagulation too early after high bleeding risk procedures
• Not providing patients with clear written instructions about when to stop and restart Eliquis 1

Following these guidelines for perioperative management of Eliquis in patients with impaired renal function will help minimize both bleeding complications and thromboembolic events.