How should apixaban (direct oral anticoagulant) be managed in patients undergoing surgery?

Perioperative Management of Apixaban

Apixaban should be discontinued at least 48 hours prior to high bleeding risk surgeries and 24 hours prior to low bleeding risk procedures, with resumption 24-72 hours postoperatively based on bleeding risk. 1

Preoperative Management

Timing of Discontinuation Based on Bleeding Risk

• High bleeding risk procedures (30-day risk of major bleeding >2%):

  • Discontinue apixaban 2 days before surgery (skip 1 dose) 2
  • This corresponds to approximately 4 half-lives expired and minimal (6%) residual anticoagulant effect at surgery 2
  • Examples: cardiac surgery, intracranial/spinal surgery, major abdominal surgery, procedures in highly vascular organs, neuraxial anesthesia 2

• Low-to-moderate bleeding risk procedures (30-day risk of major bleeding 0-2%):

  • Discontinue apixaban 1 day before surgery 2
  • Examples: arthroscopy, colonoscopy biopsy, abdominal hernia repair 2

• Minimal bleeding risk procedures (30-day risk approximately 0%):

  • May continue apixaban without interruption 2
  • Examples: minor dermatologic procedures, cataract surgery, minor dental procedures 2

Special Considerations

• Renal function: While apixaban is less dependent on renal clearance (25%) than some other DOACs, consider longer interruption in patients with impaired renal function 2

• Bridging anticoagulation: Not routinely recommended during the perioperative period due to the rapid offset and onset of action of DOACs 2

• Measuring residual anticoagulant effect: Not routinely required before procedures 2

Postoperative Management

Timing of Resumption Based on Bleeding Risk

• High bleeding risk surgery:

  • Resume apixaban 2-3 days after surgery (48-72 hours postoperatively) 2
  • Consider reduced dose (2.5 mg twice daily) for the first 2-3 days in patients at high risk for thromboembolism 2

• Low bleeding risk surgery:

  • Resume apixaban on the day after surgery (24 hours postoperatively) at the usual dose (5 mg twice daily) 2
  • Ensure at least 24 hours have elapsed to allow sufficient time for wound hemostasis 2

General Principles for Resumption

• Resume apixaban only after adequate hemostasis has been established 1
• Wait at least 6 hours after the end of the invasive procedure before resuming therapy 2
• Consider postoperative factors that may affect drug absorption (e.g., bowel dysmotility after major abdominal surgery) 2

Special Scenarios

• Urgent/emergent surgery: If surgery cannot be delayed for at least 24-48 hours after the last dose, consider prothrombin complex concentrate (PCC) to reverse anticoagulant effect 3

• Neuraxial anesthesia: Requires minimal to no residual anticoagulant effect (4-5 half-life interruptions pre-procedure) due to potentially devastating consequences of epidural bleeding 2

Practical Considerations

• Half-life considerations: Apixaban has a half-life of 7-8 hours, with 25% renal clearance 2

• Thrombotic risk: A patient's thromboembolic risk should drive whether there is a need for an aggressive perioperative antithrombotic strategy, while procedural bleeding risk determines the postprocedural management 2

• Clinical evidence: In a prospective observational study, 94% of patients who had apixaban held for at least 48 hours before surgery achieved clinically insignificant anticoagulant levels (≤30 ng/mL) 4

• Missed doses: If a dose is missed, take it as soon as possible on the same day and resume twice-daily administration; do not double the dose to make up for a missed dose 1