What is the recommended duration of Eliquis (apixaban) use after surgery for Deep Vein Thrombosis (DVT) prophylaxis?

Duration of Eliquis (Apixaban) for DVT Prophylaxis After Surgery

For DVT prophylaxis after surgery, Eliquis (apixaban) should be administered for 35 days (5 weeks) following hip replacement surgery and for 12-14 days following knee replacement surgery. 1, 2

Recommended Dosing Regimen

• The recommended dose of apixaban for VTE prophylaxis after orthopedic surgery is 2.5 mg taken orally twice daily 1
• The initial dose should be taken 12 to 24 hours after surgery, when adequate hemostasis has been established 1
• For hip replacement surgery, the recommended duration is 35 days (5 weeks) 1, 2
• For knee replacement surgery, the recommended duration is 12 days 1, though some guidelines suggest 10-14 days 3

Evidence Supporting Duration Recommendations

• Clinical trials (ADVANCE-2 and ADVANCE-3) that established apixaban's efficacy used these specific durations - 35 days for hip arthroplasty and 10-14 days for knee arthroplasty 3
• Apixaban demonstrated superior efficacy compared to enoxaparin in preventing VTE in these trials while maintaining a favorable bleeding profile 3
• The American College of Chest Physicians guidelines recommend a minimum of 10-14 days of thromboprophylaxis after major orthopedic surgery, with consideration of extending up to 35 days for patients at higher risk 3

Special Considerations for Perioperative Management

• If a surgical procedure is needed while on apixaban, the medication should be discontinued at least 24-48 hours prior to procedures with low bleeding risk and 48 hours prior to procedures with moderate to high bleeding risk 1
• For patients requiring neuraxial anesthesia or spinal puncture, timing between apixaban administration and these procedures requires careful consideration to minimize risk of spinal/epidural hematoma 1, 3
• Resumption of apixaban should occur only after adequate hemostasis has been established following surgery 1, 3

Risk Factors Warranting Extended Prophylaxis

• Extended prophylaxis beyond the minimum duration should be considered for patients with:
  • Previous history of VTE 3, 4
  • Active cancer 3
  • Prolonged immobilization 3
  • Advanced age 3
  • Higher stage of disease 3

Common Pitfalls to Avoid

• Inadequate duration of prophylaxis, especially premature discontinuation before completing the recommended course 2, 1
• Failure to adjust for renal function, as impaired renal function may affect drug clearance 2
• Overlooking potential drug interactions, particularly with P-glycoprotein inhibitors and CYP3A4 inhibitors 3, 2
• Improper timing with neuraxial anesthesia, which requires special attention to avoid spinal/epidural hematoma 1

Comparison with Other Anticoagulants

• Unlike traditional prophylaxis with LMWH that often requires daily injections, apixaban offers the convenience of oral administration 5, 6
• Efficacy of apixaban is comparable to enoxaparin for thromboprophylaxis, with potentially lower rates of clinically relevant bleeding 5, 6
• Extended prophylaxis with apixaban has not shown superior efficacy compared to shorter courses of enoxaparin in medical patients, and was associated with more bleeding 3

The evidence strongly supports using apixaban for the full recommended duration to optimize the balance between thromboprophylaxis efficacy and bleeding risk, with 35 days for hip replacement and 12-14 days for knee replacement being the standard of care.