Can a Patient Stop Eliquis (Apixaban) Cold Turkey?
No, patients should not stop Eliquis (apixaban) abruptly without medical guidance, as discontinuation significantly increases the risk of stroke and thromboembolism. 1
Critical Safety Warning
The FDA label explicitly warns that stopping apixaban increases stroke risk in patients with atrial fibrillation. Patients must consult their prescribing physician before discontinuation. 1
If apixaban must be stopped (for surgery or procedures), alternative anticoagulation should be considered during the interruption period to maintain thrombotic protection. 1
The risk of thrombotic events is particularly elevated in the first 7-10 days after stopping anticoagulation, with a three-fold increased risk of cardiovascular or cerebrovascular events. 2
When Temporary Discontinuation May Be Necessary
For Elective Procedures
For high-risk bleeding procedures, the last dose of apixaban should be taken at least 48 hours before the procedure in patients with normal renal function. 2
For patients with creatinine clearance 30-50 mL/min taking apixaban, extend the discontinuation period to 72 hours before procedures. 2
For low-risk procedures, omitting only the morning dose on the day of the procedure is sufficient. 2
Apixaban can typically be resumed 6 hours after hemostasis is achieved following a procedure, given its rapid onset of action (1-4 hours). 2, 3
For Active Bleeding
In cases of major bleeding, apixaban should be temporarily discontinued until hemostasis is achieved and the patient is clinically stable. 2
For life-threatening bleeding, consider reversal agents such as andexanet alfa (specific for apixaban) or prothrombin complex concentrates. 2, 3
Once bleeding is controlled, restart apixaban based on thrombotic risk assessment, typically within 1-3 days for high-risk patients. 4
High-Risk Situations Where Discontinuation Is Particularly Dangerous
Patients with the following conditions face the highest thrombotic risk if apixaban is stopped: 4
- Mechanical heart valves (especially mitral position)
- Recent stroke or TIA within 3 months
- Venous thromboembolism within 3 months
- History of unprovoked or recurrent VTE
- Left atrial or ventricular thrombus
Bridging Therapy Considerations
Bridging with heparin is NOT necessary when temporarily stopping apixaban due to its short half-life (approximately 12 hours) and rapid offset of anticoagulant effect. 2
Bridging is only recommended for warfarin in high-risk patients, not for direct oral anticoagulants like apixaban. 2
Common Pitfalls to Avoid
Never assume a patient can safely stop apixaban without assessing their specific thrombotic risk. The indication for anticoagulation (atrial fibrillation, VTE, etc.) determines the consequences of discontinuation. 1
Do not confuse apixaban's short half-life with safety for abrupt discontinuation. While the drug clears quickly, the underlying thrombotic risk remains and may actually increase acutely after stopping. 2
Avoid stopping apixaban for minor bleeding that can be managed with local measures. The risk of thrombosis often outweighs the bleeding risk in these situations. 2
When Permanent Discontinuation May Be Appropriate
Consider permanent discontinuation only in specific circumstances: 4
- Nonvalvular atrial fibrillation with CHA₂DS₂-VASc score <2 (men) or <3 (women)
- Temporary indication for anticoagulation has been completed (e.g., 3-6 months post-VTE in provoked cases)
- Patient declines continuation after informed discussion of risks
- Severe, recurrent, life-threatening bleeding despite optimal management
Restarting After Discontinuation
When restarting apixaban after temporary discontinuation, no loading dose is required due to rapid achievement of therapeutic levels within 3-4 hours. 2
Assess and address any modifiable bleeding risk factors (medication interactions, renal function changes, fall risk) before restarting. 3
Annual reassessment is mandatory for patients on extended anticoagulation, particularly evaluating changes in renal function, bleeding history, and fall risk. 3