When should Eliquis (apixaban) be held before knee surgery?

When to Hold Apixaban (Eliquis) Before Knee Surgery

Apixaban should be discontinued at least 48 hours prior to knee surgery due to the moderate to high risk of bleeding associated with this procedure. 1

Preoperative Management Guidelines

• Apixaban should be discontinued at least 48 hours before elective knee surgery or invasive procedures with moderate or high risk of clinically significant bleeding 1
• For procedures with low bleeding risk or where bleeding would be non-critical and easily controlled, apixaban can be discontinued 24 hours before surgery 1
• Bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required 1, 2
• For patients receiving neuraxial anesthesia (spinal/epidural), longer interruption times up to 5 days may be needed to minimize the risk of spinal hematoma 3, 2

Factors Affecting Timing of Discontinuation

• Renal function: Patients with impaired renal function may require longer discontinuation periods as apixaban is partially (25%) cleared by the kidneys 2, 3
• Bleeding risk of procedure: Knee surgery is generally considered a procedure with moderate to high bleeding risk 2
• Patient-specific factors: Age, body weight, and concomitant medications may influence the decision 3
• Drug interactions: Patients taking P-glycoprotein inhibitors or CYP3A4 inhibitors may have higher apixaban levels and may require longer discontinuation periods 2, 1

Postoperative Resumption Protocol

• Apixaban should be restarted after knee surgery only when adequate hemostasis has been established 1, 2
• For knee surgery (high bleeding risk procedure):
  • Resume apixaban 2-3 days after surgery (48-72 hours postoperative) 2
  • Consider using a reduced dose initially if the patient is at high risk for thromboembolism 2
• For patients at high thromboembolism risk who require earlier anticoagulation, consider using prophylactic doses of heparin or fondaparinux at least 6 hours after the procedure 3, 2

Common Pitfalls to Avoid

• Restarting apixaban too soon after surgery, which increases bleeding risk 2, 3
• Discontinuing apixaban for too long, which increases thromboembolism risk 2
• Failing to consider drug interactions that may affect apixaban levels 1, 2
• Not accounting for renal function when determining the timing of discontinuation 3
• Overlapping anticoagulants when transitioning between agents 3, 1

Special Considerations for Knee Surgery

• The recommended prophylactic dose of apixaban after knee replacement is 2.5 mg twice daily for 12 days 1, 4
• For patients already on therapeutic apixaban who are undergoing knee surgery, the timing of resumption should be based on hemostasis rather than a fixed schedule 2, 1
• If an epidural catheter was placed for pain control, therapeutic anticoagulation must be delayed until after catheter removal 5, 2

By following these guidelines, clinicians can minimize both bleeding complications and thromboembolism risk when managing patients on apixaban who require knee surgery.