When should apixaban (apixaban) be held before surgery?

When to Hold Apixaban Before Surgery

Hold apixaban for 1 day (24 hours) before low-to-moderate bleeding risk procedures and 2 days (48 hours) before high bleeding risk procedures in patients with normal renal function. 1

Preoperative Discontinuation Timeline

Low-to-Moderate Bleeding Risk Procedures

• Stop apixaban 1 day (24 hours) before surgery 1, 2
• This corresponds to approximately 2-3 half-lives, achieving minimal residual anticoagulant effect 2
• Examples include: arthroscopy, laparoscopic cholecystectomy, abdominal hernia repair, colonoscopy with biopsy, and coronary angiography 2

High Bleeding Risk Procedures

• Stop apixaban 2 days (48 hours) before surgery 1, 2
• This corresponds to approximately 4-5 half-lives, achieving minimal (6%) residual anticoagulant effect 2, 3
• Examples include: cardiac surgery, intracranial/spinal surgery, major abdominal surgery, and surgery in highly vascular organs 2, 3

Special Consideration: Neuraxial Procedures

• Stop apixaban 3 days (72 hours) before spinal or epidural anesthesia, even with normal renal function 2, 3
• This extended duration is critical due to the catastrophic risk of epidural hematoma 2

Impact of Renal Function

Renal function assessment is mandatory before determining the discontinuation timeline 2, as apixaban has 25-27% renal clearance 1, 4:

• Normal renal function (CrCl ≥80 mL/min): Follow standard timing above 1
• Moderate renal impairment (CrCl 30-50 mL/min): Consider longer interruption periods, though specific guidance is limited 1, 3
• The FDA label recommends at least 48 hours for moderate-to-high bleeding risk procedures 5

Bridging Anticoagulation

Do not use bridging anticoagulation during the interruption period 1, 2, 3:

• Bridging increases hemorrhagic risk without reducing thrombotic events 3
• Apixaban's rapid offset and onset of action eliminates the need for bridging during the 24-48 hour interruption 2, 3
• Reserve bridging only for very high thrombotic risk patients after multidisciplinary discussion 3

Evidence Supporting This Approach

The 2022 American College of Chest Physicians guideline provides the highest quality evidence for this recommendation 1. A prospective observational study confirmed that 94% of patients achieved clinically insignificant apixaban concentrations (≤30 ng/mL) after discontinuation for at least 48 hours, with only one clinically significant nonmajor bleeding event reported 6.

Postoperative Resumption

Resume apixaban at least 24 hours after low bleeding risk surgery once adequate hemostasis is established 1, 3, 5:

• For low bleeding risk procedures: Resume full dose (5 mg twice daily) 24 hours postoperatively 1, 3
• For high bleeding risk procedures: Resume 48-72 hours postoperatively 1, 3
• Consider reduced dose (2.5 mg twice daily) for first 2-3 days in high thrombotic risk patients undergoing major surgery 1, 3

Critical Pitfalls to Avoid

• Do not use INR or aPTT to guide timing, as apixaban's effect on these tests is inconsistent and unreliable for surgical clearance 2
• Do not routinely measure apixaban concentrations when recommended interruption periods are followed 3
• Do not resume therapeutic-dose apixaban in the presence of an epidural catheter 3
• Do not double the dose to make up for a missed preoperative dose 5

Pharmacokinetic Rationale

Apixaban has a half-life of 7-8 hours in patients with normal renal function 1, 2, 4. The recommended discontinuation periods are based on achieving 2-3 half-lives (mild residual effect) for low-risk procedures and 4-5 half-lives (minimal effect) for high-risk procedures 2. Maximum concentration occurs 3-4 hours after oral administration, with approximately 50% oral bioavailability 4.