What is the perioperative management plan for a 65-year-old patient with a history of atrial fibrillation on Eliquis (apixaban) undergoing femur fracture repair surgery?

Perioperative Management of Apixaban in a 65-Year-Old Patient with Atrial Fibrillation Undergoing Femur Fracture Repair

For a 65-year-old patient with atrial fibrillation on apixaban (Eliquis) requiring femur fracture repair surgery, apixaban should be discontinued 2 days before surgery (skip 2 doses) and resumed 2-3 days after surgery, assuming adequate hemostasis is achieved. 1

Preoperative Management

Risk Assessment

• Femur fracture repair is considered a high bleeding risk procedure, requiring careful anticoagulation management 1
• The patient's age (65 years) and history of atrial fibrillation place them at moderate-to-high risk for thromboembolic events 1
• Assess renal function before determining the appropriate discontinuation period, as impaired renal function affects apixaban clearance 2

Apixaban Interruption Schedule

• For high bleeding risk procedures like femur fracture repair, apixaban should be discontinued 2 days before surgery 1
• This means the last dose should be taken 3 days before the procedure 1
• No heparin bridging is required for patients on apixaban, as the rapid offset and onset of action of DOACs obviates the need for bridging therapy 1, 2

Laboratory Testing

• Routine coagulation tests (PT/INR) should be obtained, though they may not accurately reflect apixaban activity 2
• In urgent cases like femur fracture repair, specific apixaban levels may be considered if available, though not routinely required 1

Intraoperative Considerations

• Neuraxial anesthesia (if planned) requires minimal to no residual anticoagulant effect, confirming the need for at least 2 days of apixaban interruption 1
• Inform the surgical team about the patient's anticoagulation status to ensure appropriate hemostatic measures are available 1

Postoperative Management

Resumption of Anticoagulation

• Resume apixaban 2-3 days after surgery (48-72 hours postoperatively) once adequate hemostasis is achieved 1
• For patients at high risk for thromboembolism, consider administering a reduced dose initially (2.5 mg twice daily instead of 5 mg twice daily) 1
• The standard dose can be resumed after 2-3 days of the reduced dose regimen 1

Monitoring

• Monitor for signs of bleeding or thromboembolism during the perioperative period 1
• Assess renal function postoperatively, especially if the procedure or patient's condition could affect kidney function 2

Special Considerations

• If the patient has impaired renal function (CrCl <50 mL/min), a longer preoperative interruption period may be necessary 1
• Perioperative atrial fibrillation is associated with increased one-year mortality in elderly patients after hip fracture repair, highlighting the importance of appropriate management 3
• Recent evidence suggests apixaban may have a more favorable safety profile compared to other DOACs like rivaroxaban, with lower rates of major ischemic and hemorrhagic events 4

Common Pitfalls to Avoid

• Unnecessary bridging with heparin products can increase bleeding risk without reducing thrombotic risk 2
• Resuming full-dose anticoagulation too early in cases with incomplete hemostasis can lead to bleeding complications 2
• Failing to assess renal function before determining the appropriate discontinuation period can increase bleeding risk 2
• Delaying surgery unnecessarily due to concerns about anticoagulation may lead to poorer outcomes in hip fracture patients 5