Can I give apixaban (Eliquis) to a patient with cervical fusion?

Management of Apixaban (Eliquis) in a Patient with Recent Cervical Fusion

Yes, you can give apixaban (Eliquis) to a patient with recent cervical fusion (POD#0), but timing is critical to minimize bleeding risk and should be based on the surgical bleeding risk assessment.

Perioperative Management of Apixaban After Cervical Fusion

Immediate Post-Operative Period (POD#0)

• For patients who had cervical fusion, which is considered a procedure with high bleeding risk, apixaban should be restarted with caution 1
• Wait at least 24-72 hours after surgery before restarting therapeutic anticoagulation to ensure adequate surgical hemostasis 1
• If venous thromboprophylaxis is indicated before full anticoagulation can be safely restarted, consider using prophylactic doses of heparin or LMWH starting at least 6 hours after the end of surgery 1

Timing of Apixaban Resumption

• For procedures with high bleeding risk like cervical spine surgery:
  • If once-daily regimen: Resume the next morning if morning dose, or the evening of the next day if evening dose 1
  • If twice-daily regimen: Resume the next day (not same day as surgery) 1
• Full therapeutic anticoagulation should typically be resumed 24-72 hours postoperatively, only after confirming surgical hemostasis 1

Special Considerations for Cervical Fusion Patients

Bleeding Risk Assessment

• Cervical spine surgery carries a significant risk of postoperative hematoma (5.6% in one large series), which can be catastrophic if it causes cord compression 2
• Postoperative hematoma requiring surgical intervention occurs in approximately 2.4% of anterior cervical fusion cases 2
• Patients with abnormal coagulation profiles have higher complication rates and extended hospital stays after cervical fusion 3

Neuraxial Considerations

• If an epidural catheter was placed for pain control, therapeutic anticoagulation must be delayed until after catheter removal 1
• The French Working Group on Perioperative Hemostasis strongly recommends against performing spinal or epidural procedures in patients with possible residual apixaban effect 1

Dosing Considerations

• Standard dosing for apixaban is 5 mg twice daily for most indications 4
• Reduced dose of 2.5 mg twice daily is recommended for patients with at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 4
• Monitor renal function postoperatively as surgical procedures may affect kidney function and potentially alter apixaban clearance 1

Monitoring and Follow-up

Bleeding Risk Monitoring

• Monitor closely for signs of bleeding at the surgical site during the first 72 hours after restarting apixaban 1, 2
• Be vigilant for symptoms of neurological compromise which could indicate epidural hematoma formation 4
• Patients with cervical fusion have a mortality rate of 0.1% and overall morbidity rate of 19.3%, with bleeding complications being significant contributors 2

Specific Contraindications

• Avoid apixaban in patients with severe renal impairment (CrCl <15 mL/min) 1, 4
• Use with caution in patients with hepatic impairment (transaminases >2 times upper limit of normal or total bilirubin >1.5 times upper limit of normal) 1

By following these guidelines, you can safely administer apixaban to your patient with recent cervical fusion while minimizing the risk of bleeding complications and optimizing anticoagulation efficacy.