When can Eliquis (apixaban) be restarted after a Transurethral Resection of the Prostate (TURP) procedure?

When to Restart Eliquis After TURP

Eliquis (apixaban) should be restarted 48-72 hours (2-3 days) after TURP once adequate hemostasis has been established. 1

Rationale for Timing

TURP is classified as a high bleeding risk urological procedure due to the significant association between anticoagulation/antiplatelet therapy and increased bleeding complications. 2 The 48-72 hour delay allows for:

• Critical hemostasis period: Gross hematuria typically persists for several days post-TURP, with bleeding directly related to the amount of tissue resected and operative duration. 3
• Peak bleeding risk window: Secondary hemorrhage requiring readmission can occur up to 28 days post-TURP, but the highest risk period is within the first 72 hours. 4
• Adequate wound healing: The prostatic fossa requires time to establish stable hemostasis before reintroducing full anticoagulation. 2

Specific Resumption Protocol

Standard Approach (48-72 Hours)

• Wait minimum 48 hours after TURP before restarting apixaban 1
• Confirm adequate hemostasis: Ensure bladder irrigation has stopped, catheter output is clear or minimally blood-tinged, and no active bleeding is evident 1
• No bridging required: Do not use prophylactic heparin or LMWH during the 48-72 hour waiting period 2

High Thromboembolism Risk Patients

For patients at elevated thrombotic risk (e.g., recent stroke, mechanical heart valve, recent VTE):

• Consider reduced initial dosing: Start with apixaban 2.5 mg twice daily for the first 1-2 days after the 48-72 hour waiting period 1
• Transition to full dose: Resume standard therapeutic dose (typically 5 mg twice daily) after the initial reduced-dose period 1
• Cardiology consultation: Strongly advised for patients with prosthetic valves or recent cardiac events to balance competing risks 2

Critical Pitfalls to Avoid

Resuming Too Early (Before 48 Hours)

• Significantly increases bleeding risk, particularly given that TURP patients on anticoagulation have documented higher rates of:
  • Prolonged bladder irrigation (median 24 vs 22 hours) 5
  • Extended catheterization (median 42 vs 24 hours) 5
  • Blood transfusions (9% vs 1%) 5
  • Postoperative urinary retention (18% vs 6%) 5
  • Rehospitalization for secondary hemorrhage 5, 4

Delaying Too Long (Beyond 72 Hours)

• Increases thrombotic risk in patients with atrial fibrillation or history of VTE 2, 1
• Balance must be struck between bleeding and thrombotic complications 2

Using Bridging Anticoagulation

• Not recommended for NOAC interruption around TURP 2
• Bridging with LMWH during the perioperative period increases bleeding complications without clear benefit for most patients 2
• Exception: Only consider in extremely high-risk thrombotic patients (e.g., mechanical mitral valve) with multidisciplinary consultation 2

Monitoring After Resumption

• Patient education: Advise high fluid intake for 3 weeks post-TURP to prevent clot retention 3
• Watch for delayed bleeding: Secondary hemorrhage can occur up to 4 weeks postoperatively, though most bleeding resolves within 3 weeks 3
• Signs requiring urgent evaluation: Clot retention, inability to void, heavy bleeding requiring catheter reinsertion 3
• Renal function: Verify adequate kidney function before resuming apixaban, as surgical procedures may affect renal status 6

Special Considerations

Concurrent Antiplatelet Therapy

• If patient was on aspirin alone preoperatively: Can be continued perioperatively without significantly increased bleeding risk 2, 5
• If patient was on clopidogrel: Higher bleeding risk documented (19% transfusion rate vs 1% in controls); consider delaying restart beyond 72 hours if possible 5
• Dual antiplatelet therapy: Should not be interrupted within 12 months of drug-eluting stent or 3 months of bare metal stent placement 2

Alternative: Laser Prostatectomy

For anticoagulated patients requiring prostate surgery, laser prostatectomy can be safely performed without discontinuing anticoagulation, offering a lower bleeding risk alternative to traditional TURP. 2