How do you discontinue apixaban (a direct oral anticoagulant) when it's no longer needed?

How to Discontinue Apixaban When No Longer Needed

Simply stop apixaban without tapering or bridging therapy when anticoagulation is no longer indicated. 1

Discontinuation Process

Apixaban can be abruptly discontinued without dose tapering, bridging anticoagulation, or laboratory monitoring. 1 The drug's pharmacokinetic properties allow for straightforward cessation:

• Half-life: Approximately 12 hours in patients with normal renal function 2
• Clearance timeline: Anticoagulant effect diminishes progressively over 24-48 hours, with clinically insignificant levels (≤30 ng/mL) typically achieved within 48-76 hours 3
• No reversal agent needed: Unlike warfarin, apixaban does not require vitamin K or other reversal agents for routine discontinuation 4

Clinical Scenarios for Discontinuation

When Anticoagulation Indication Resolves

Stop apixaban immediately when the clinical indication (e.g., atrial fibrillation, venous thromboembolism) no longer exists or when transitioning to comfort care. 4 Document the rationale for discontinuation in the medical record. 4

Perioperative Management

For elective surgery or invasive procedures:

• Low bleeding risk procedures: Discontinue at least 24 hours before the procedure 1
• Moderate to high bleeding risk procedures: Discontinue at least 48 hours before the procedure 1
• No bridging anticoagulation is generally required during the 24-48 hour interruption period 1

The 2018 European Heart Rhythm Association provides more granular guidance based on renal function 5:

• CrCl ≥80 mL/min: Stop ≥24 hours before low-risk procedures, ≥48 hours before high-risk procedures 5
• CrCl 50-79 mL/min: Stop ≥24 hours before low-risk procedures, ≥48 hours before high-risk procedures 5
• CrCl 30-49 mL/min: Stop ≥24 hours before low-risk procedures, ≥48 hours before high-risk procedures 5
• CrCl 15-29 mL/min: Stop ≥36 hours before low-risk procedures, ≥48 hours before high-risk procedures 5

Switching to Another Anticoagulant

When transitioning from apixaban to another anticoagulant:

• To warfarin: Discontinue apixaban and begin both parenteral anticoagulation and warfarin at the time of the next scheduled apixaban dose; discontinue parenteral anticoagulation when INR reaches therapeutic range 1
• To other oral or parenteral anticoagulants: Discontinue apixaban and begin the new anticoagulant at the usual time of the next apixaban dose 1

Special Considerations

Renal Impairment

Patients with chronic kidney disease may have prolonged apixaban clearance. 6 In one case report, detectable anti-Xa levels persisted for >10 days after the last dose in an elderly patient with chronic kidney disease. 6 For patients with CrCl <30 mL/min undergoing procedures, consider extending the discontinuation period to 36-48 hours or longer. 5

Bleeding Events

For nonmajor bleeding, temporarily discontinue apixaban until hemostasis is achieved and the patient is clinically stable. 5 Reversal agents are not routinely indicated for nonmajor bleeding. 5

For major bleeding, discontinue apixaban immediately and consider andexanet alfa (specific reversal agent for factor Xa inhibitors) if available. 5 The 2020 ACC Expert Consensus recommends andexanet alfa dosing based on the timing and dose of the last apixaban intake. 5

Comfort Care/End-of-Life

In patients transitioning to comfort care, discontinue apixaban as it provides no benefit for symptom management and carries ongoing bleeding risk. 4 The focus shifts from preventing future thrombotic events to optimizing quality of life. 4 No tapering or reversal is needed; simply stop the medication. 4

Common Pitfalls

• Do not taper apixaban: Unlike some medications, apixaban does not require gradual dose reduction 1
• Do not routinely bridge with heparin: Bridging is not generally necessary for the 24-48 hour perioperative interruption 1
• Do not assume standard clearance in renal impairment: Patients with CrCl <30 mL/min may require longer discontinuation periods 5, 6
• Avoid premature discontinuation without clinical justification: Discontinuation in atrial fibrillation patients is associated with high 30-day rates of death (5.8%), thromboembolism (2.6%), and major bleeding (3.0%) 7

Resumption After Temporary Interruption

Restart apixaban at the usual dose as soon as adequate hemostasis has been established after surgery or procedures. 1 The 2018 European guidelines suggest resuming >24 hours post-low bleeding risk interventions and 48-72 hours post-high bleeding risk interventions. 5