How long should Eliquis (apixaban) be stopped prior to orbital floor fracture repair?

Stopping Eliquis (Apixaban) Prior to Orbital Floor Fracture Repair

Apixaban should be discontinued at least 48 hours prior to orbital floor fracture repair, as this is considered a procedure with moderate to high bleeding risk. 1

Timing of Apixaban Discontinuation

The timing of discontinuation depends on the patient's renal function and bleeding risk:

• Normal or mildly impaired renal function (CrCl ≥50 mL/min):

  • Stop apixaban at least 48 hours before surgery 1, 2
  • For patients with additional risk factors (age ≥80 years, body weight ≤60 kg, or concomitant P-glycoprotein inhibitors like amiodarone), consider extending to 72 hours 2

• Moderately impaired renal function (CrCl 30-50 mL/min):

  • Stop apixaban at least 48-72 hours before surgery 2

• Severely impaired renal function (CrCl 15-29 mL/min):

  • Stop apixaban at least 48 hours before surgery, consider extending to 72 hours 2

Considerations for Orbital Floor Fracture Surgery

The timing of orbital floor fracture repair itself depends on several clinical factors:

• Immediate repair (within 24-48 hours) is indicated for:

  • Entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 2
  • "White-eyed blow-out fracture" with muscle entrapment (especially in children) 2
  • Globe subluxation into the maxillary sinus 2

• Early repair (within 1-2 weeks) is recommended for:

  • Symptomatic diplopia with positive forced ductions or entrapment on CT 2
  • Large floor fractures, hypoglobus, or progressive infraorbital hypoesthesia 2
  • Early enophthalmos or hypoglobus causing facial asymmetry 2

• Delayed repair may be appropriate for:

  • Restrictive strabismus and unresolved enophthalmos 2
  • Cases requiring observation of minimal diplopia without significant enophthalmos or hypoglobus 2

Perioperative Management Protocol

Pre-operative:

1. Assess bleeding risk:

   • Orbital floor fracture repair is considered a moderate-to-high bleeding risk procedure 1
   • Discontinue apixaban at least 48 hours before surgery 1

2. No bridging anticoagulation:

   • Bridging with LMWH or heparin is not recommended during the 48-hour period after stopping apixaban 2

Post-operative:

1. Resumption of anticoagulation:

   • Resume apixaban at least 24 hours after surgery if adequate hemostasis has been achieved 1
   • For higher bleeding risk, consider waiting 48-72 hours post-surgery 2

2. If immediate anticoagulation is needed:

   • Consider prophylactic doses of LMWH or UFH at least 6 hours after the end of surgery 2

Important Considerations and Pitfalls

• Avoid measurement of drug levels: Routine measurement of apixaban levels before surgery is not recommended 2

• Concomitant medications: If the patient is taking P-glycoprotein inhibitors (e.g., amiodarone, verapamil) or strong CYP3A4 inhibitors, consider extending the discontinuation period by an additional 24 hours 2

• Post-surgical recovery: Patients typically regain orbital floor strength by 24 days after repair, so normal activities can usually be resumed approximately 3 weeks after uncomplicated orbital floor fracture repair 3

• Individualized approach: The timing of both anticoagulant discontinuation and orbital fracture repair should be determined based on the specific clinical scenario, balancing the risk of bleeding against the urgency of the orbital repair 2