When should apixaban (direct oral anticoagulant) be discontinued before epidural surgery?

When to Stop Apixaban Before Epidural Surgery

Stop apixaban at least 5 days (120 hours) before epidural procedures in patients with normal renal function, and do not perform the procedure if adequate cessation time cannot be confirmed. 1

Why Epidural Procedures Require Extended Cessation

Epidural procedures are classified as very high hemorrhagic risk because bleeding in the confined epidural space can cause spinal cord compression, and surgical hemostasis cannot be performed in this location. 1 This makes the bleeding risk fundamentally different from other surgical procedures, where direct surgical control of hemorrhage is possible.

• The 5-day cessation period for epidural procedures is significantly longer than the 48 hours required for standard high-risk surgeries with normal renal function. 1
• The American Society of Regional Anesthesia and Pain Medicine specifically recommends the 5-day cessation due to the catastrophic consequences of epidural hematoma. 1
• The European Society of Anesthesiology concurs with this 5-day recommendation to account for the high bleeding risk and inability to control hemorrhage in the epidural space. 1

Renal Function Considerations

For patients with normal renal function (CrCl >50 mL/min): Stop apixaban 5 days before the epidural procedure. 1

For patients with impaired renal function: The European Heart Journal recommends stopping apixaban 5 days before the procedure, with no adjustment needed compared to normal renal function for apixaban specifically. 1 However:

• For moderate renal impairment, consider biological monitoring of drug levels if available. 1
• For severe renal impairment, strongly consider measuring apixaban levels before proceeding. 1

This differs from the FDA label guidance, which states that apixaban should be discontinued at least 48 hours prior to elective surgery with moderate or high bleeding risk. 2 The discrepancy reflects the unique catastrophic risk profile of epidural procedures specifically.

Critical Safety Warnings

Do not perform spinal or epidural anesthesia in patients with possible residual DOAC concentration. 1 This is particularly critical in:

• Patients over 80 years of age 1
• Patients with renal failure 1
• Any patient where adequate discontinuation time cannot be confirmed 1

The French Working Group on Perioperative Hemostasis strongly emphasizes this prohibition because even minimal residual anticoagulation can lead to epidural hematoma. 1

Additional Risk Factors Requiring Extended Cessation

Consider extending the cessation period beyond 5 days if the patient has: 1

• P-glycoprotein inhibitors (e.g., verapamil, amiodarone, quinidine)
• Strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir)
• Age over 80 years

These factors increase apixaban levels or reduce drug clearance, potentially leaving residual anticoagulation even after 5 days. 1

Bridging Anticoagulation

Do not use bridging anticoagulation with heparin or low-molecular-weight heparin during the cessation period. 1 The American College of Cardiology recommends no bridging except in very high thrombotic risk patients, as bridging increases bleeding risk without proven benefit for DOACs. 1

This represents a key difference from older warfarin management, where bridging was more commonly employed. 3

Resumption After Epidural Procedure

Resume apixaban 48-72 hours after the procedure, once adequate hemostasis is established. 1 Critical considerations:

• Do not resume therapeutic anticoagulation if an epidural catheter remains in place. 1
• If an epidural catheter is still present, therapeutic anticoagulation must not be resumed until after catheter removal. 1
• Prophylactic heparin can be used if thromboprophylaxis is needed while the catheter is in place. 1

The European Society of Anesthesiology emphasizes that premature resumption with a catheter in situ dramatically increases epidural hematoma risk. 1

Common Pitfalls to Avoid

• Do not assume 48 hours is sufficient: While the FDA label states 48 hours for high-risk procedures generally 2, epidural procedures specifically require 5 days due to the inability to achieve surgical hemostasis in the epidural space. 1

• Do not ignore age and renal function: Patients over 80 or with renal impairment may have prolonged apixaban clearance, necessitating extended cessation or drug level monitoring. 1

• Do not bridge routinely: Unlike warfarin management, bridging with heparin increases bleeding risk without reducing thrombotic events for DOACs. 1

• Do not resume too early: Confirm adequate hemostasis and ensure any epidural catheter has been removed before restarting apixaban. 1