Do Patients on Eliquis Still Need DVT Prophylaxis?
No, patients already taking therapeutic-dose Eliquis (apixaban) for an approved indication do not need additional DVT prophylaxis, as they are already anticoagulated. However, the specific clinical context determines whether prophylaxis is appropriate or if adjustments are needed.
When Therapeutic Eliquis Provides Adequate Protection
Patients on therapeutic-dose apixaban for the following indications are already anticoagulated and do not require additional DVT prophylaxis 1:
- Atrial fibrillation (5 mg twice daily, or 2.5 mg twice daily with dose-reduction criteria) 1
- Active VTE treatment (10 mg twice daily for 7 days, then 5 mg twice daily) 1
- Secondary prevention of recurrent DVT/PE (2.5 mg twice daily after completing initial treatment) 1
These patients are therapeutically anticoagulated and adding prophylactic anticoagulation would be redundant and increase bleeding risk without benefit 2.
Perioperative Management: When to Stop and Restart
Stopping Eliquis Before Surgery
Eliquis must be discontinued before surgery, and the timing depends on bleeding risk 1:
- High bleeding risk procedures (neurosurgery, neuraxial anesthesia): Stop 48 hours before surgery 1
- Moderate bleeding risk procedures: Stop 48 hours before surgery 1
- Low bleeding risk procedures: Stop 24 hours before surgery 1
Bridging anticoagulation is NOT generally required during the 24-48 hour interruption period 2, 1.
Providing DVT Prophylaxis After Surgery
Once Eliquis is stopped for surgery, patients DO need DVT prophylaxis until therapeutic anticoagulation is restarted 2:
- Use heparin (UFH or LMWH) or fondaparinux starting at least 6 hours after the procedure 2
- Continue prophylactic anticoagulation until surgical hemostasis is established 2
- Resume therapeutic-dose Eliquis 24-72 hours postoperatively when hemostasis is adequate 2, 1
- Give the first therapeutic dose 12 hours after the last prophylactic LMWH dose 2
Critical caveat: If an epidural catheter is present, therapeutic anticoagulation must be given as heparin (not Eliquis) to allow safe catheter removal 2.
Special Populations Requiring Prophylaxis Despite Being on Eliquis
Orthopedic Surgery Patients
For hip or knee replacement surgery, the FDA-approved prophylactic dose of apixaban is 2.5 mg twice daily 1:
- Hip replacement: 35 days of prophylaxis starting 12-24 hours post-surgery 1
- Knee replacement: 12 days of prophylaxis starting 12-24 hours post-surgery 1
If a patient was on therapeutic Eliquis pre-operatively, switch to the prophylactic dose (2.5 mg twice daily) post-operatively, then return to therapeutic dosing after the prophylaxis period 2.
Hospitalized Medical Patients
Patients admitted for acute medical illness who were previously on Eliquis for atrial fibrillation do NOT need additional prophylaxis 2. Their therapeutic anticoagulation provides adequate VTE protection 2.
Exception: If Eliquis must be held due to bleeding or high bleeding risk, then mechanical prophylaxis (intermittent pneumatic compression) should be used until Eliquis can be safely restarted 2.
Cancer Patients
Cancer patients on therapeutic Eliquis for atrial fibrillation or prior VTE are already anticoagulated and do not need additional prophylaxis 2.
However, for cancer surgery: Follow the perioperative management algorithm above—stop Eliquis pre-operatively, use prophylactic LMWH post-operatively, then resume therapeutic Eliquis 2.
For ambulatory cancer patients starting chemotherapy: If they are already on therapeutic Eliquis for another indication, they do not need additional prophylaxis 2.
Common Pitfalls to Avoid
Do not "double anticoagulate": Never add prophylactic-dose anticoagulation to a patient already on therapeutic-dose Eliquis 2.
Do not perform neuraxial procedures on patients with residual Eliquis levels: Ensure adequate washout time (48 hours minimum, longer if renal impairment) before spinal/epidural anesthesia 2, 1.
Do not forget to restart anticoagulation post-operatively: The highest risk period for VTE is when anticoagulation is interrupted—bridge with prophylactic heparin until therapeutic Eliquis can be safely resumed 2.
Monitor renal function post-operatively: Adjust Eliquis dosing if creatinine clearance changes after surgery 2.
Avoid overlapping prophylactic and therapeutic anticoagulation: When transitioning from prophylactic LMWH back to therapeutic Eliquis, wait 12 hours after the last LMWH dose 2.