When should Eliquis (apixaban) be restarted after surgery?

When to Restart Eliquis (Apixaban) After Surgery

Restart Eliquis as soon as adequate hemostasis is achieved, which can be as early as 6 hours after low bleeding risk procedures, but should be delayed 24-72 hours after high bleeding risk surgeries.

Timing Based on Bleeding Risk and Hemostasis

Low Bleeding Risk Procedures

• Resume apixaban 6 hours or more after the procedure if adequate hemostasis is confirmed 1, 2, 3
• The FDA label specifically states that apixaban should be restarted "as soon as adequate hemostasis has been established" 3
• For procedures with immediate and complete hemostasis, resumption can occur 6-8 hours post-intervention 4

High Bleeding Risk Procedures

• Delay resumption for 24-48 hours (or up to 48-72 hours) until hemostasis is secure 4, 1, 2
• For many surgical interventions, resuming full-dose anticoagulation within the first 48-72 hours may carry a bleeding risk that outweighs the cardioembolic risk 4
• The European Society of Cardiology guidelines emphasize that therapeutic anticoagulation should be deferred 48-72 hours after invasive procedures 4

Critical Decision Points

Assess Hemostasis First

• Never restart apixaban if there is ongoing bleeding or surgical contraindication 1
• Confirm adequate hemostasis before resuming therapy 1
• If unexpected heavy bleeding occurs, delay resumption until bleeding is controlled 1

Bridging Considerations

• Do not use bridging anticoagulation with heparin when restarting apixaban 1, 2
• For procedures associated with immobilization, consider reduced venous thromboprophylactic or intermediate-dose LMWH 6-8 hours after surgery if hemostasis is achieved, while deferring full therapeutic anticoagulation with apixaban for 48-72 hours 4
• Bridging increases bleeding risk without reducing thrombotic risk 1, 2

Dosing When Restarting

Standard Dosing

• Resume the regular twice-daily dosing schedule starting with the evening dose on the day of the procedure (for low-risk procedures) 1
• Return to the patient's pre-operative maintenance dose 3

High Thrombotic Risk Patients

• If there are concerns about ongoing bleeding but the patient is at high thrombotic risk, consider appropriate thromboprophylaxis rather than full-dose apixaban 1
• The absence of a specific antidote must be considered if bleeding occurs or re-intervention is needed 4

Common Pitfalls to Avoid

• Do not resume full-dose anticoagulation too early after high bleeding risk surgery 1
• Do not double the dose to make up for missed doses during the perioperative period 3
• Do not use bridging therapy with heparin products when stopping or restarting DOACs 1, 2
• Do not restart if INR or coagulation parameters suggest residual anticoagulant effect from other agents 3

Special Populations

Renal Impairment

• Exercise additional caution in patients with renal impairment, as approximately 27% of apixaban clearance occurs via renal excretion 5
• Consider slightly longer delays in resumption for patients with significant renal dysfunction

Elderly Patients

• Patients over 80 years may require more conservative timing due to increased bleeding risk 2
• Ensure complete hemostasis before resumption in this population