How long should apixaban (apixaban) be held before hip revision surgery?

Apixaban Interruption for Hip Revision Surgery

Apixaban should be discontinued 48 hours (2 days) before hip revision surgery in patients with normal or mildly impaired renal function (CrCl ≥50 mL/min), with the last dose taken on the morning 2 days prior to the procedure. 1, 2

Standard Interruption Protocol

For patients with normal renal function:

• Stop apixaban 48 hours before surgery, which corresponds to approximately 4 half-lives of drug elimination and results in approximately 6% residual anticoagulant effect at the time of surgery 1
• The FDA label specifies that apixaban should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of unacceptable or clinically significant bleeding 2
• Hip revision surgery qualifies as high bleeding risk due to potential for significant hemorrhagic consequences including epidural hematoma and potential paralysis 1

Renal Function Adjustments

For patients with moderate renal impairment (CrCl 30-50 mL/min):

• Extend the interruption period to 3-4 days (72-96 hours) before surgery 1
• Apixaban has 25% renal clearance, making impaired renal function delay drug elimination 1
• Verify renal function before finalizing the interruption plan, as patients with declining renal function can accumulate apixaban and experience catastrophic bleeding complications 1

Bridging Anticoagulation

Do not use bridging anticoagulation:

• Bridging with heparin or low molecular weight heparin is not recommended during the perioperative interruption period 1
• 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 1

Postoperative Resumption

Resume apixaban 48-72 hours after surgery:

• Restart apixaban 2-3 days after surgery once adequate hemostasis is established, and at least 6 hours after the end of the surgical procedure 1
• Consider starting with a reduced dose (2.5 mg twice daily) for the first 2-3 days in patients at high thromboembolism risk 1
• Do not resume therapeutic-dose apixaban while an epidural catheter is in place to minimize bleeding complications 1

Evidence Supporting 48-Hour Interruption

Clinical validation:

• A prospective cohort study demonstrated that apixaban discontinuation for at least 48 hours before a procedure resulted in clinically insignificant anticoagulation (94% of patients achieved concentrations ≤30 ng/mL) 3
• The median time between last dose and presurgery blood sampling was 76 hours for those achieving safe concentrations 3
• Only one clinically significant nonmajor bleeding event was reported in the perioperative period 3

Critical Implementation Details

Timing of last dose:

• The last dose should be taken on the morning 2 days before surgery (48 hours prior) 1
• For surgery scheduled in the morning, this means the last dose is taken 2 mornings before the procedure 1

Common pitfalls to avoid:

• Do not count the day of surgery as one of the interruption days—the full 48 hours must elapse before the procedure 1
• Do not use bridging anticoagulation, which increases bleeding risk without benefit 1
• Do not resume apixaban until adequate hemostasis is confirmed, typically 48-72 hours postoperatively 1