When can Eliquis (apixaban) be restarted after surgery?

When to Restart Eliquis (Apixaban) After Surgery

For low bleeding risk procedures, restart apixaban 24 hours after surgery at the usual dose; for high bleeding risk procedures, restart 48-72 hours after surgery once adequate hemostasis is established. 1, 2, 3

Risk-Stratified Approach to Resumption

Low Bleeding Risk Procedures

• Resume apixaban 24 hours after surgery at the regular therapeutic dose (typically 5 mg twice daily) 1, 2, 4
• Ensure at least 24 hours have elapsed to allow sufficient time for wound hemostasis 1, 4
• Examples include arthroscopy, colonoscopy with biopsy, and abdominal hernia repair 4
• The patient may only leave the facility if any peri-interventional bleeding has completely stopped 1

High Bleeding Risk Procedures

• Resume apixaban 48-72 hours (2-3 days) after surgery once adequate hemostasis has been established 1, 2, 4, 3
• For patients at high risk of thromboembolism, consider starting with a reduced dose of 2.5 mg twice daily for the first 1-2 days, then transition to the full therapeutic dose 1, 2, 4
• Examples include cardiac surgery, intracranial/spinal surgery, major abdominal surgery, and anterior cervical fusion 2, 4
• The American Society of Regional Anesthesia and Pain Medicine specifically recommends the 48-72 hour window for high-risk procedures 2

Dosing Strategy After High-Risk Surgery

Two acceptable approaches exist for high-risk patients:

1. Standard approach: Wait 48-72 hours, then resume full therapeutic dose (5 mg twice daily) 1, 2, 3

2. Stepwise approach for high thrombotic risk patients:

   • Start with 2.5 mg twice daily for 1-2 days after the 48-72 hour waiting period 1, 2
   • Then increase to full therapeutic dose (5 mg twice daily) 1, 2

Bridging Anticoagulation

• No bridging anticoagulation with heparin is required during the 24-72 hour window after surgery 1, 2, 4
• The FDA label confirms that bridging during the 24-48 hours after stopping apixaban is not generally required 3

Special Considerations

Renal Function

• Patients with impaired renal function may require longer interruption periods before surgery and potentially delayed resumption 1, 2
• Apixaban has 25% renal clearance, making it less dependent on kidney function than some other anticoagulants 1, 4

Postoperative Factors

• Consider factors that may affect drug absorption, such as bowel dysmotility after major abdominal surgery 4
• Wait at least 6 hours after the end of the invasive procedure before resuming therapy 4
• Monitor for signs of bleeding after resuming anticoagulation 2

Critical Pitfalls to Avoid

• Resuming too early (less than 48 hours) after high-risk surgery significantly increases bleeding risk 2
• Delaying anticoagulation too long in high thrombotic risk patients increases the risk of thrombotic events 2
• Poor communication between surgical and medical teams regarding the resumption plan can lead to errors 2
• Starting full therapeutic doses immediately after high-risk surgery without considering a stepwise approach in high-risk patients 1, 2

Administration Options for Patients Unable to Swallow

• Apixaban tablets may be crushed and suspended in water, 5% dextrose in water, or apple juice, or mixed with applesauce and promptly administered orally 3
• Alternatively, tablets may be crushed and suspended in 60 mL of water or D5W and delivered through a nasogastric tube 3
• Crushed apixaban is stable in these solutions for up to 4 hours 3