When to discontinue Eliquis (apixaban) before surgery?

From the Guidelines

Eliquis (apixaban) should typically be stopped 48 hours before elective surgery with standard bleeding risk and 72 hours before procedures with high bleeding risk, as recommended by the most recent guidelines 1.

Perioperative Management of Eliquis

The decision to discontinue Eliquis before surgery is based on the patient's renal function and the type of surgery.

• For patients with normal or mildly impaired renal function, stopping Eliquis 48 hours before standard risk surgery and 72 hours before high-risk surgery is recommended 1.
• For patients with impaired kidney function (creatinine clearance less than 30 mL/min), the timeframes should be extended to 72 hours for standard risk procedures and 96 hours for high-risk procedures.

Considerations for Emergency Procedures

In cases of emergency procedures, it is essential to inform the surgical team about Eliquis use, as they may need to use reversal agents like andexanet alfa.

Importance of Consultation

Always consult with both the prescribing physician and surgeon before stopping Eliquis, as they may recommend a different schedule based on the patient's specific thrombotic risk, and in some cases may prescribe "bridging" therapy with shorter-acting anticoagulants during the perioperative period.

Guideline Recommendations

The 2022 American College of Chest Physicians clinical practice guideline recommends a pharmacokinetic-based approach for the interruption of direct oral anticoagulants (DOACs) before elective surgery, which supports the recommended timeframes for stopping Eliquis 1.

• The guideline suggests that withholding DOACs for 2 full days before a surgery/procedure should result in minimal to no residual anticoagulant effect at the time of surgery.
• However, for patients with severely impaired renal function or those taking drugs that may interfere with DOAC clearance, a longer duration of pre-operative DOAC interruption may be required.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

Discontinuation of Eliquis (apixaban) before surgery:

• For elective surgery or invasive procedures with a moderate or high risk of bleeding, discontinue apixaban at least 48 hours prior to the procedure.
• For elective surgery or invasive procedures with a low risk of bleeding, discontinue apixaban at least 24 hours prior to the procedure. 2

From the Research

Discontinuation of Eliquis (Apixaban) Before Surgery

• The decision to discontinue Eliquis (apixaban) before surgery should be based on the individual patient's risk of thromboembolism and bleeding, as well as the type of surgery being performed 3, 4, 5, 6, 7.
• For patients undergoing elective surgical or nonsurgical procedures, a standardized approach to perioperative apixaban management involves classifying the risk of procedure-related bleeding as minimal, low to moderate, or high risk 6.
• For minimal bleeding risk procedures, apixaban may be continued or discontinued on the day of the procedure 6.
• For low to moderate bleeding risk procedures, apixaban should typically be discontinued 1-2 days before the operation and restarted 1-2 days after 5, 6, 7.
• For high bleeding risk procedures, apixaban should be stopped 2 days prior to the operation and restarted 2 days after 6.

Specific Discontinuation Recommendations

• One study recommends discontinuing apixaban for at least 2 days before surgery 5.
• Another study suggests that discontinuing apixaban for at least 48 hours before surgery is safe and results in a clinically insignificant degree of anticoagulation prior to a surgical procedure 7.
• A review of the literature recommends discontinuing apixaban 1-2 days before surgery for most patients, but notes that the optimal discontinuation time may vary depending on the individual patient's risk factors and the type of surgery being performed 6.

Considerations for Discontinuation

• The decision to discontinue apixaban should be made in consultation with the patient's healthcare provider and should take into account the individual patient's risk of thromboembolism and bleeding 3, 4, 5, 6, 7.
• Laboratory testing to measure preoperative apixaban levels may be useful to determine whether patients should receive a reversal agent prior to an emergent or urgent procedure 6.