Is bridging anticoagulation necessary in a patient with a factor V mutation and a history of Deep Vein Thrombosis (DVT) when holding Eliquis (apixaban) for 2 days prior to minor surgery?

Perioperative Management of Apixaban in a Patient with Factor V Mutation and History of DVT

For a patient with factor V mutation and history of DVT who is holding Eliquis (apixaban) for 2 days prior to minor surgery, bridging anticoagulation is not recommended.

Risk Assessment and Recommendations

Apixaban Interruption Management

• Apixaban should be discontinued for 1-2 days before minor surgery depending on the bleeding risk of the procedure 1
• The FDA label for apixaban states: "Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required" 2
• For minor surgery with low-to-moderate bleeding risk, apixaban should be stopped 1 day before the procedure 1
• For minor surgery with high bleeding risk, apixaban should be stopped 2 days before the procedure 1

Thrombotic Risk Considerations

• Factor V Leiden mutation represents an enduring risk factor for thrombosis, but this alone does not necessitate bridging therapy 1
• The history of DVT is important, but the recency of the DVT is a critical factor in determining bridging necessity 1
• For patients with VTE at low-to-moderate risk for thromboembolism, guidelines suggest against heparin bridging during anticoagulant interruption 1
• Only patients with recent VTE (<3 months), severe thrombophilia, or selected types of active cancer would be considered high-risk enough to warrant bridging 1

Bleeding vs. Thrombotic Risk

• Bridging anticoagulation has been associated with increased bleeding risk without clear evidence of thrombotic prevention 3
• Studies show that heparin bridging increases the risk of major bleeding with no significant reduction in recurrent VTE 1
• In a systematic review of VKA-treated patients with VTE requiring elective surgery, bridging was associated with higher bleeding rates (3.9% vs 0.4%) with no effect on recurrent VTE (0.7% vs 0.5%) 1

Practical Management Algorithm

1. Assess procedure bleeding risk:

   • If minor surgery with low-to-moderate bleeding risk: hold apixaban for 1 day 1
   • If minor surgery with high bleeding risk: hold apixaban for 2 days 1

2. Assess patient thrombotic risk:

   • High risk (requires bridging): Recent VTE (<3 months), severe thrombophilia with recent thrombosis 1
   • Low-to-moderate risk (no bridging needed): Factor V mutation with remote history of DVT (>3 months) 1

3. Resumption of anticoagulation:

   • Resume apixaban 12-24 hours after surgery when adequate hemostasis is achieved 2
   • For twice-daily regimen like apixaban, resume the evening of the same day if hemostasis is adequate 1

Common Pitfalls to Avoid

• Overusing bridging anticoagulation in low-risk patients, which increases bleeding risk without clear benefit 3
• Underestimating the bleeding risk of bridging therapy, which can be substantial even with minor procedures 4
• Failing to consider the timing of the last DVT event when making bridging decisions 1
• Assuming that all patients with thrombophilia (like Factor V Leiden) automatically need bridging 1

The rapid offset and onset of action of DOACs like apixaban makes bridging unnecessary in most cases, unlike with vitamin K antagonists 1. For a patient with Factor V mutation and past history of DVT (assuming not recent), holding apixaban for 2 days before minor surgery without bridging provides the optimal balance between preventing thrombosis and avoiding excessive bleeding risk.