What is the recommended duration for stopping apixaban (apixaban) before surgery?

Apixaban Discontinuation Before Surgery

Apixaban should be discontinued at least 48 hours before high bleeding risk procedures and at least 24 hours before low bleeding risk procedures, with longer discontinuation times for patients with impaired renal function. 1, 2

Timing of Apixaban Discontinuation

The timing for stopping apixaban before surgery depends on several factors:

Bleeding Risk Assessment

• Low bleeding risk procedures: Discontinue apixaban at least 24 hours before the procedure 1, 2

  • Examples: Minor dental procedures, cataract surgery, endoscopy without biopsy, superficial surgery, pacemaker implantation

• High bleeding risk procedures: Discontinue apixaban at least 48 hours before the procedure 1, 2

  • Examples: Major orthopedic surgery, extensive oral surgery, major cancer surgery, neurosurgery, complex cardiovascular procedures

Renal Function Considerations

• Normal renal function: Follow standard discontinuation times (24-48 hours based on bleeding risk) 1
• Impaired renal function: Consider longer discontinuation periods as apixaban has approximately 25% renal clearance 3, 1

Evidence Supporting Recommendations

Recent clinical evidence strongly supports these recommendations. The ADIOS study (2022) demonstrated that apixaban discontinuation for at least 48 hours before procedures resulted in clinically insignificant anticoagulation levels in most patients. In this study, 94% of patients had apixaban concentrations ≤30 ng/mL, which is considered safe for surgery 4.

The FDA label for apixaban explicitly states that it "should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding" and "at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding" 2.

Resumption of Apixaban After Surgery

Resumption timing is equally important:

• Low bleeding risk procedures: Resume apixaban 24 hours after surgery (next day) 3, 1
• High bleeding risk procedures: Resume apixaban 48-72 hours after surgery 3, 1

For patients at high risk for thromboembolism, consider using a reduced dose (2.5 mg twice daily) when initially resuming apixaban after high bleeding risk procedures 3.

Common Pitfalls to Avoid

1. Inadequate discontinuation time: Not allowing sufficient time for apixaban clearance before surgery increases bleeding risk
2. Restarting too soon: Resuming full-dose apixaban too soon after surgery can lead to bleeding complications
3. Inappropriate bridging: Bridging anticoagulation during the 24-48 hours after stopping apixaban and prior to surgery is generally not required 2
4. Failure to adjust for renal function: Patients with impaired renal function may need longer discontinuation periods
5. Not considering drug interactions: Patients taking P-gp and strong CYP3A4 inhibitors may have higher apixaban levels and might need longer discontinuation periods 2

Special Considerations

• Elderly patients (>80 years): Require careful monitoring due to increased bleeding risk and potentially reduced renal function 1
• Emergency surgery: If surgery cannot be delayed, consider prothrombin complex concentrate (PCC) to reverse anticoagulant effects 5
• Resumption criteria: Restart apixaban only after adequate hemostasis has been established 2

This evidence-based approach to perioperative management of apixaban balances the risks of thromboembolism and bleeding, with timing of discontinuation tailored to the bleeding risk of the procedure and the patient's renal function.