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

Timing of Apixaban (Eliquis) Discontinuation Before Orbital Floor Fracture Repair

For orbital floor fracture repair surgery, apixaban (Eliquis) should be discontinued at least 48 hours prior to surgery if renal function is normal, and longer if there is renal impairment. 1

Apixaban Discontinuation Protocol

Based on Renal Function and Bleeding Risk

• For patients with normal or mildly impaired renal function (CrCl ≥50 mL/min):

  • Last dose: 3 days before surgery (skip 4 doses) for high bleeding risk procedures 2
  • Last dose: 2 days before surgery (skip 2 doses) for low bleeding risk procedures 2

• For patients with moderate renal impairment (CrCl 30-50 mL/min):

  • Last dose: 4 days before surgery (skip 6 doses) for high bleeding risk procedures 2
  • Last dose: 3 days before surgery (skip 4 doses) for low bleeding risk procedures 2

FDA Label Guidance

• The FDA label for apixaban specifically 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" 1
• For procedures with low bleeding risk, apixaban should be discontinued at least 24 hours prior 1

Orbital Floor Fracture Repair Considerations

Bleeding Risk Classification

• Orbital floor fracture repair should be considered a high bleeding risk procedure due to:
  • The proximity to critical structures (eye, optic nerve)
  • Risk of retrobulbar hematoma, which can lead to vision impairment or blindness 3
  • Limited space for blood accumulation in the orbital cavity 3

Timing of Surgery

• Timing of orbital fracture repair depends on specific clinical scenarios:
  • Immediate repair (within 24 hours) for muscle/tissue entrapment with oculocardiac reflex, "white-eyed blow-out fracture," or globe subluxation 2
  • Repair within 2 weeks for symptomatic diplopia with positive forced ductions, large floor fractures, hypoglobus, or early enophthalmos 2
  • Delayed repair for restrictive strabismus and unresolved enophthalmos 2

Perioperative Management Protocol

Pre-Surgery

1. Assess patient's renal function to determine appropriate discontinuation timeline 2
2. For most patients with normal renal function, stop apixaban at least 48 hours before surgery 1, 4
3. For patients with renal impairment, extend the discontinuation period as outlined above 2
4. Consider checking anti-Xa activity prior to surgery if available (levels ≤30 ng/mL are generally safe for surgery) 4

Post-Surgery

• For high bleeding risk procedures like orbital floor repair:

  • Resume apixaban 2-3 days (48-72 hours) after surgery when adequate hemostasis has been established 2
  • Consider reduced dose initially (2.5 mg twice daily) for 1-2 days before returning to regular dosing 2

• For patients at high risk for thromboembolism:

  • Consider a reduced dose regimen for the first 2-3 days after surgery 2
  • Then resume full therapeutic dosing 2

Special Considerations and Pitfalls

• Bridging anticoagulation during the 24-48 hours after stopping apixaban and prior to surgery is not generally required 1
• The risk of retrobulbar hematoma is higher in patients with comminuted fractures and those on anticoagulants 3
• Recent research confirms that apixaban discontinuation for at least 48 hours before procedures results in clinically insignificant anticoagulation levels in most patients 4
• Apixaban has a half-life of approximately 12 hours, which is longer than the 7-8 hours reported in earlier studies 5
• Wound strength in orbital floor repairs is generally regained 24 days after repair, so anticoagulation should be carefully managed during this healing period 6