Resuming Apixaban After Anterior Cervical Fusion
For patients undergoing anterior cervical fusion, apixaban (Eliquis) should be resumed 48-72 hours after surgery once adequate hemostasis has been established.
Risk Classification and Timing
Anterior cervical fusion is considered a high bleeding risk procedure due to:
- Risk of postoperative hematoma formation which can cause airway compromise 1
- Proximity to vital neurovascular structures 1
- Potential for catastrophic consequences if bleeding occurs 2
Preoperative Management
- Apixaban should be discontinued at least 48 hours prior to anterior cervical fusion 3
- For patients with impaired renal function, a longer discontinuation period may be necessary 2
Postoperative Resumption
- High bleeding risk surgery (including anterior cervical fusion): Resume apixaban 2-3 days (48-72 hours) after surgery 2
- Ensure adequate surgical hemostasis has been established before restarting 3
- No bridging anticoagulation is typically required during the 48-72 hour window after surgery 2
Dosing Considerations
When restarting apixaban after anterior cervical fusion:
- For patients at high risk of thromboembolism: Consider starting with a reduced dose (apixaban 2.5 mg twice daily) for the first 1-2 days 2
- For standard risk patients: Resume the regular therapeutic dose (5 mg twice daily for most patients) after the 48-72 hour waiting period 2
Special Considerations
Monitoring After Resumption
- Watch for signs of postoperative bleeding or neurological deterioration in the first few days after restarting anticoagulation 1
- Most postoperative hematomas occur within the first 24-72 hours after surgery, which overlaps with the recommended time for anticoagulant resumption 1
Risk Factors for Bleeding Complications
- History of smoking 1
- Multilevel fusion procedures 4
- Prolonged surgical time 1
- Abnormal preoperative coagulation parameters 1
Common Pitfalls to Avoid
- Resuming full-dose anticoagulation too early (less than 48 hours) after surgery, which increases bleeding risk 2
- Delaying anticoagulation for too long in high-risk thrombotic patients 2
- Failing to consider patient-specific factors such as renal function, age, and weight when determining dosing 3
- Not communicating the anticoagulation resumption plan clearly between surgical and medical teams 2
Remember that the timing of apixaban resumption should balance the risk of postoperative bleeding against the risk of thrombotic events. The 48-72 hour window after confirming adequate hemostasis represents the optimal balance for most patients undergoing anterior cervical fusion 2, 3.