What are the preoperative management guidelines for patients taking apixaban (Direct Oral Anticoagulant) prior to surgery?

Preoperative Management of Apixaban

For patients taking apixaban who require surgery, discontinue apixaban at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of bleeding, and at least 24 hours prior to procedures with a low risk of bleeding. 1

Timing of Apixaban Discontinuation

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

High Bleeding Risk Procedures

• Discontinue apixaban 3 days before surgery (skip 4 doses for twice daily regimen) in patients with normal or mildly impaired renal function (CrCl ≥50 mL/min) 2, 3
• Examples include cardiac surgery, intracranial/spinal surgery, and major abdominal surgery 3
• This corresponds to approximately 4 half-lives expired and minimal (6%) residual anticoagulant effect at surgery 2
• For patients with moderate renal impairment (CrCl 30-50 mL/min), discontinue apixaban 4 days before surgery (skip 6 doses) 2, 3

Low-to-Moderate Bleeding Risk Procedures

• Discontinue apixaban 2 days before surgery (skip 2 doses for twice daily regimen) in patients with normal or mildly impaired renal function 2, 3
• Examples include arthroscopy, colonoscopy biopsy, and abdominal hernia repair 3
• For patients with moderate renal impairment, discontinue apixaban 3 days before surgery (skip 4 doses) 2

Minimal Bleeding Risk Procedures

• For procedures with minimal bleeding risk (e.g., minor dental or skin procedures), apixaban may be continued, or if there is concern about excessive bleeding, discontinued only on the day of the procedure 4
• The French Working Group on Perioperative Hemostasis suggests that for low bleeding risk procedures, the last intake of apixaban should be on the morning of the day before the planned invasive procedure 2

Bridging Anticoagulation

• Bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required 1
• Preoperative bridging by unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is not recommended 2
• There is no need to routinely measure the concentration of apixaban before the procedure 2

Postoperative Management

Resumption of Apixaban

• Restart apixaban after surgical or other procedures as soon as adequate hemostasis has been established 1
• For high bleeding risk surgery, resume apixaban 2-3 days after surgery (48-72 hours postoperative) 2
• Consider a reduced dose (2.5 mg twice daily) for the first 2-3 days in patients at high risk for thromboembolism 2, 3
• For low bleeding risk surgery, resume apixaban on the day after surgery (24 hours postoperative) at the usual dose (5 mg twice daily) 2, 3
• Wait at least 6 hours after the end of the invasive procedure before resuming therapy 2

Special Considerations

• Recent research shows that apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to surgery 5
• In early 2013, there was no antidote for apixaban, nor any specific treatment with proven efficacy for severe bleeding linked to this drug 6 (Note: This has changed with the development of andexanet alfa as a reversal agent)
• Consider postoperative factors that may affect drug absorption, such as bowel dysmotility after major abdominal surgery 3
• The patient's thromboembolic risk should drive whether there is a need for an aggressive perioperative antithrombotic strategy 3

Practical Algorithm for Apixaban Management

1. Assess bleeding risk of the procedure:

   • High risk: Major surgery, neuraxial anesthesia
   • Low-to-moderate risk: Minor procedures
   • Minimal risk: Dental, dermatological procedures

2. Assess patient's renal function:

   • Normal/mild impairment (CrCl ≥50 mL/min)
   • Moderate impairment (CrCl 30-50 mL/min)

3. Stop apixaban according to risk and renal function:

   • High risk + normal renal function: Stop 3 days before
   • High risk + moderate renal impairment: Stop 4 days before
   • Low risk + normal renal function: Stop 2 days before
   • Low risk + moderate renal impairment: Stop 3 days before
   • Minimal risk: Consider continuing or stopping day of procedure

4. Resume apixaban based on bleeding risk:

   • High risk: Resume 2-3 days after surgery
   • Low risk: Resume 24 hours after surgery
   • Always ensure adequate hemostasis before resuming