Resuming Eliquis (Apixaban) After Surgery
For most patients, Eliquis (apixaban) should be restarted 24 hours after low bleeding risk surgery and 48-72 hours after high bleeding risk surgery, once adequate hemostasis has been established. 1, 2
Timing of Resumption Based on Bleeding Risk
Low Bleeding Risk Procedures
- Resume Eliquis 24 hours after surgery (on the day after surgery) at the regular dose (typically 5 mg twice daily for most patients) 3, 2
- No bridging anticoagulation is typically required during this period 4, 1
- Ensure adequate hemostasis has been achieved before resuming anticoagulation 1
High Bleeding Risk Procedures
- Resume Eliquis 48-72 hours after surgery once adequate hemostasis has been established 3, 2
- For patients at high risk of thromboembolism, consider starting with a reduced dose (2.5 mg twice daily) for the first 1-2 days after surgery 3, 2
- Return to the regular therapeutic dose after the initial reduced dosing period 2
Special Considerations
Patient-Specific Factors
- Renal function: Patients with impaired renal function may require additional consideration when resuming anticoagulation, though apixaban is less affected by renal impairment than some other anticoagulants 2, 4
- Thrombotic risk: Balance the risk of bleeding against the risk of thromboembolism when determining exact timing of resumption 3, 2
Practical Administration
- If a dose is missed, take it as soon as possible on the same day and resume the twice-daily schedule 1
- Do not double the dose to make up for a missed dose 1
- For patients unable to swallow tablets, Eliquis can be crushed and suspended in water, apple juice, or mixed with applesauce 1
Evidence Quality and Clinical Implications
The recommendations for resuming Eliquis after surgery are based on clinical practice guidelines and the FDA drug label. The 2022 American College of Chest Physicians guideline provides the most recent and highest quality evidence, suggesting resumption of anticoagulation at least 24 hours after surgery 3.
Common Pitfalls to Avoid
- Resuming full-dose anticoagulation too early (less than 24 hours) after surgery increases bleeding risk 2
- Delaying anticoagulation for too long in high-risk thrombotic patients can increase thrombotic events 2
- Lack of clear communication between surgical and medical teams about the anticoagulation resumption plan can lead to errors 2
- Failing to assess for adequate hemostasis before resuming anticoagulation 1
Monitoring After Resumption
- Monitor for signs of bleeding after resuming anticoagulation 3
- No routine laboratory monitoring is required for apixaban, unlike warfarin 5
- If unexpected heavy bleeding occurs after resumption, consider temporarily discontinuing apixaban and consulting with a specialist 4
Following these guidelines will help balance the risks of bleeding and thromboembolism when resuming Eliquis after surgical procedures.