When to start Eloquis (apixaban) after hysterectomy?

Timing of Apixaban Initiation After Hysterectomy

Apixaban (Eliquis) should be started 24-72 hours after hysterectomy, once adequate surgical hemostasis has been established, with the exact timing depending on bleeding risk assessment and whether neuraxial anesthesia was used. 1

General Principles for Apixaban Initiation After Surgery

• For procedures with high bleeding risk, apixaban should be restarted with caution based on surgical bleeding risk assessment 1
• Full therapeutic anticoagulation should typically be resumed 24-72 hours postoperatively, only after confirming surgical hemostasis 1
• For twice-daily regimens, resume apixaban the next day, not the same day as surgery 1

Specific Considerations for Hysterectomy

Timing Based on Anesthesia Type

• If neuraxial anesthesia (epidural/spinal) was used:
  • Wait at least 4 hours after catheter removal before starting apixaban 2
  • Do not start apixaban earlier than 12 hours after the neuraxial block was performed 2
  • For therapeutic doses, wait at least 24 hours after the block was performed 2

Dosing Recommendations

• For VTE prophylaxis after hysterectomy for cancer:
  • Prophylactic dose: apixaban 2.5 mg twice daily 3
  • Duration: 28 days for extended thromboprophylaxis in gynecologic cancer surgery 3, 4
• For patients requiring therapeutic anticoagulation:
  • Resume the patient's regular therapeutic dose once hemostasis is established 1

Special Considerations

• If significant intraoperative bleeding complications occurred, consider delaying apixaban initiation and potentially using unfractionated heparin (UFH) initially due to its shorter half-life and reversibility 2
• For patients with epidural catheters for pain control, therapeutic anticoagulation must be delayed until after catheter removal 1
• Monitor renal function postoperatively as surgical procedures may affect kidney function and potentially alter apixaban clearance 1

Evidence on Apixaban After Gynecologic Surgery

• A randomized clinical trial comparing apixaban (2.5 mg twice daily) with enoxaparin (40 mg daily) for 28 days after gynecologic cancer surgery found no significant differences in major bleeding events (0.5% vs 0.5%) or venous thromboembolic events (1.0% vs 1.5%) 3
• A real-world study showed apixaban was an effective and safe alternative to enoxaparin after laparotomies in gynecologic oncology patients, with no difference in VTE rates (4% vs 3%) and no readmissions for bleeding in the apixaban group 4
• Patient satisfaction was significantly greater with apixaban compared to enoxaparin regarding ease of taking the medication (98.9% vs 58.8%) 3

Common Pitfalls to Avoid

• Initiating apixaban too early after surgery, especially in patients who received neuraxial anesthesia, which increases the risk of spinal hematoma 2, 1
• Failing to adjust timing based on renal function, as impaired kidney function can lead to drug accumulation 1
• Overlapping anticoagulants when transitioning between agents, which can increase bleeding risk 5
• Inadequate duration of prophylaxis in high-risk patients, particularly those with gynecologic malignancy 4, 3