Apixaban Preoperative Discontinuation
For patients with normal renal function (CrCl ≥50 mL/min), hold apixaban for 2 days before low-to-moderate bleeding risk procedures and 3 days before high bleeding risk procedures. 1
Discontinuation Based on Bleeding Risk and Renal Function
Normal or Mild Renal Impairment (CrCl ≥50 mL/min)
- Low-to-moderate bleeding risk surgery: Last dose 2 days before surgery (skip 2 doses), corresponding to 2-3 half-lives 1
- High bleeding risk surgery: Last dose 3 days before surgery (skip 4 doses), corresponding to 4-5 half-lives 1
Moderate Renal Impairment (CrCl 30-50 mL/min)
- Low-to-moderate bleeding risk surgery: Last dose 3 days before surgery (skip 4 doses) 1
- High bleeding risk surgery: Last dose 4 days before surgery (skip 6 doses) 1
FDA-Approved Guidance
The FDA label provides a simplified approach: discontinue apixaban at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding, and at least 24 hours prior to procedures with low bleeding risk. 2 This represents the minimum safe discontinuation period and aligns with the guideline recommendations for normal renal function.
Bleeding Risk Classification
High bleeding risk procedures include: 1
- Cardiac, intracranial, or spinal surgery
- Surgery in highly vascular organs (kidneys, liver, spleen)
- Any major operation (duration >45 minutes)
- Neuraxial anesthesia (epidural/spinal)
- Bowel resection, nephrectomy
Low-to-moderate bleeding risk procedures include: 1
- Arthroscopy
- Laparoscopic cholecystectomy
- Abdominal hernia repair
- Colonoscopy with biopsy
- Coronary angiography (radial approach)
Pharmacokinetic Rationale
The 2022 CHEST guidelines represent the most recent high-quality evidence and recommend shorter discontinuation periods (1-2 days) compared to the older 2012 Blood guidelines (2-4 days). 1 This reflects updated understanding of apixaban's pharmacokinetics:
- Half-life: 7-8 hours in normal renal function 1, 3
- Renal clearance: Only 27% of total clearance is renal 3
- Time to minimal anticoagulation: 2-3 half-lives achieves mild residual effect; 4-5 half-lives achieves minimal effect 1
A 2022 prospective study confirmed that 48-hour discontinuation (median 76 hours in practice) resulted in 94% of patients achieving apixaban concentrations ≤30 ng/mL, with only one clinically significant bleeding event. 4
Critical Considerations
Bridging anticoagulation is NOT required during the 24-48 hour interruption period due to apixaban's rapid offset and onset of action. 1, 2
For neuraxial procedures (spinal/epidural anesthesia), the consequences of epidural hematoma are devastating, warranting the longer 3-day discontinuation period even for patients with normal renal function. 1, 5
Renal function assessment is mandatory before determining the discontinuation timeline, as moderate impairment significantly prolongs apixaban elimination and requires extended interruption periods. 1, 6
Postoperative Resumption
Resume apixaban at least 24 hours after surgery once adequate hemostasis is established. 1, 2 For high bleeding risk procedures, consider resuming at 2-3 days postoperatively. 1