When should apixaban be withheld preoperatively in a patient undergoing L3-L4 fusion decompression surgery?

Preoperative Management of Apixaban for L3-L4 Fusion Decompression Surgery

Stop apixaban 2 days (48 hours) before your L3-L4 fusion decompression surgery, with the last dose taken 2 days prior to the scheduled procedure. 1, 2, 3

Rationale for 2-Day Interruption

L3-L4 fusion decompression surgery is classified as high bleeding risk because it involves spinal surgery, which carries significant hemorrhagic consequences including epidural hematoma and potential paralysis. 1, 2

• Stopping apixaban 2 days preoperatively corresponds to approximately 4 half-lives of drug elimination, resulting in minimal (approximately 6%) residual anticoagulant effect at the time of surgery. 1, 2, 3

• The FDA label recommends discontinuing apixaban at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of unacceptable or clinically significant bleeding. 4

• This 2-day interruption period applies to patients with normal or mildly impaired renal function (creatinine clearance ≥50 mL/min). 1, 3

Adjustments for Renal Impairment

If your patient has moderate renal impairment (CrCl 30-50 mL/min), extend the interruption to 3-4 days before surgery. 2, 3

• Apixaban has 25% renal clearance, making it less dependent on kidney function than dabigatran, but impaired renal function still delays drug elimination. 2

• Patients with declining renal function can accumulate apixaban and experience catastrophic bleeding complications. 3

Critical Implementation Details

• The last dose should be taken on the morning 2 days before surgery (e.g., if surgery is scheduled for Thursday morning, the last dose is Tuesday morning). 1, 2

• Real-world evidence confirms that apixaban discontinuation for at least 48 hours results in clinically insignificant anticoagulation, with 94% of patients achieving apixaban concentrations ≤30 ng/mL. 5

• A Delphi consensus of 20 spine surgeons recommended stopping direct oral anticoagulants (including apixaban) 2 days before elective spine surgery. 6

Do NOT Use Bridging Anticoagulation

Bridging with heparin or low molecular weight heparin is NOT recommended during the perioperative interruption period. 1, 2, 3

• The rapid offset and rapid onset of action of apixaban obviates the need for heparin bridging. 1

• Bridging increases major bleeding risk without reducing stroke or systemic embolism. 3

Common Pitfalls to Avoid

• Do not routinely measure apixaban concentrations or coagulation tests (INR, aPTT) before surgery when the recommended 2-day interruption is followed—these tests are not useful for monitoring apixaban effect. 2, 3

• Do not confuse this with low-bleeding-risk procedures, which only require 1-day interruption—spinal surgery always qualifies as high-bleeding-risk. 1, 2

• Verify the patient's renal function before finalizing the interruption plan, as unrecognized renal impairment can lead to inadequate drug clearance. 3

Postoperative Resumption

Resume apixaban 2-3 days (48-72 hours) after surgery once adequate hemostasis is established. 2, 3, 4

• Wait at least 6 hours after the end of the surgical procedure as an absolute minimum before any resumption. 2

• Consider starting with a reduced dose (2.5 mg twice daily) for the first 2-3 days in patients at high thromboembolism risk, then increase to the usual 5 mg twice daily. 2

• Do not resume therapeutic-dose apixaban while an epidural catheter is in place. 2