How long should apixaban (eliquis) be stopped before an operation (OR) in a patient with normal renal function?

Perioperative Management of Apixaban

For patients with normal renal function, apixaban should be stopped at least 24 hours before low-bleeding-risk procedures and at least 48 hours before high-bleeding-risk procedures. 1

Timing of Apixaban Discontinuation Based on Bleeding Risk

High Bleeding Risk Procedures

• Stop apixaban 48 hours or more before surgery (skip 4 doses for twice-daily regimen) 2, 1
• Examples of high-risk procedures include:
  • Major operations lasting >45 minutes 2
  • Cardiac, intracranial, or spinal surgery 2
  • Surgery in highly vascular organs (kidneys, liver, spleen) 2
  • Neuraxial anesthesia or epidural injections 2

Low-to-Moderate Bleeding Risk Procedures

• Stop apixaban 24 hours before surgery (skip 2 doses for twice-daily regimen) 2, 1
• Examples of low-to-moderate risk procedures include:
  • Arthroscopy 2
  • Coronary angiography 2
  • GI endoscopy with biopsy 2
  • Abdominal hernia repair 2

Minimal Bleeding Risk Procedures

• For procedures with minimal bleeding risk, apixaban can potentially be continued or taken on the morning of the day before the procedure 2
• Examples include:
  • Minor dermatologic procedures 2
  • Cataract surgery 2
  • Minor dental procedures 2
  • Pacemaker or cardioverter-defibrillator implantation 2

Considerations for Renal Function

• For patients with impaired renal function (CrCl 30-50 mL/min):

  • Low-to-moderate bleeding risk: Stop apixaban 3 days before surgery (skip 4 doses) 2
  • High bleeding risk: Stop apixaban 4 days before surgery (skip 6 doses) 2

• For patients with severe renal impairment (CrCl 15-29 mL/min):

  • Consider longer interruption periods, at least 36 hours before low-risk procedures 2

Important Clinical Considerations

• Bridging with heparin or LMWH is generally not recommended when stopping apixaban before surgery 2
• The rapid offset and onset of action of apixaban makes bridging unnecessary in most cases 2
• In a prospective study, stopping apixaban for at least 48 hours resulted in clinically insignificant anticoagulation levels before surgery in most patients 3
• For high-risk patients, consider measuring anti-Xa activity if available, though this approach lacks strong evidence base 2

Resuming Apixaban After Surgery

• Low-to-moderate bleeding risk procedures: Resume apixaban at least 24 hours after surgery 2
• High bleeding risk procedures: Resume apixaban 48-72 hours after surgery 2
• Ensure adequate hemostasis has been established before restarting 1
• Be cautious with immediate postoperative dosing as peak effect occurs 1-3 hours after intake 2

Common Pitfalls to Avoid

• Avoid bridging with LMWH or UFH as this increases bleeding risk without clear benefit 2
• Do not restart apixaban too soon after high bleeding risk procedures 2
• Remember that apixaban has a rapid onset of action (peak effect 1-3 hours) 2
• For emergency bleeding management, no specific antidote is widely available, though andexanet alfa has received accelerated approval for life-threatening bleeding 4, 5
• Do not assume that normal coagulation tests (PT, PTT) rule out significant anticoagulant effect of apixaban 5