Preoperative Management of Eliquis (Apixaban)
Direct Answer
Hold Eliquis for 24 hours (1 day) before low-to-moderate bleeding risk procedures and 48 hours (2 days) before high bleeding risk procedures in patients with normal renal function. 1
Bleeding Risk Stratification
High Bleeding Risk Procedures (Hold 48 hours)
- Cardiac, intracranial, or spinal surgery 1
- Surgery in highly vascular organs (kidneys, liver, spleen) 1
- Major abdominal operations (bowel resection, urologic/GI surgery with anastomosis) 1
- Any procedure lasting >45 minutes 1
- Transurethral prostate resection, nephrectomy, kidney biopsy 1
Low-to-Moderate Bleeding Risk Procedures (Hold 24 hours)
- Arthroscopy, laparoscopic cholecystectomy, abdominal hernia repair 1
- Colonoscopy with biopsy, GI endoscopy with biopsy 1
- Coronary angiography (radial approach), abdominal hysterectomy 1
- Foot/hand surgery, cutaneous/lymph node biopsies 1
Minimal Bleeding Risk Procedures (No interruption needed)
- Minor dermatologic procedures, cataract surgery, dental extractions 1
- Pacemaker/defibrillator implantation 1
Special Considerations for Neuraxial Procedures
For spinal or epidural anesthesia, hold Eliquis for 72 hours (3 days) regardless of renal function due to the catastrophic risk of epidural hematoma and lower limb paralysis. 2, 3 This extended duration applies even in patients with normal renal function because the consequences of bleeding in this location are devastating. 1
Renal Function Adjustments
Assess creatinine clearance before determining the discontinuation timeline, as apixaban has 27% renal clearance. 2, 4
- Normal renal function (CrCl ≥50 mL/min): Follow standard timing above 1
- Moderate renal impairment (CrCl 30-50 mL/min): Consider extending the interruption period by an additional day, though specific guidance is limited 2, 5
FDA-Approved Guidance
The FDA label states: "Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding. Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding." 6
Pharmacokinetic Rationale
The recommendations are based on apixaban's half-life of approximately 12 hours. 4
- 24-hour interruption = 2 half-lives, achieving some residual anticoagulant effect acceptable for low-risk procedures 1
- 48-hour interruption = 4 half-lives, achieving minimal residual anticoagulant effect for high-risk procedures 1, 3
- 72-hour interruption = 6 half-lives, ensuring near-complete drug elimination for neuraxial procedures 2
A prospective cohort study confirmed that 94% of patients achieved clinically insignificant apixaban concentrations (≤30 ng/mL) after at least 48 hours of discontinuation. 7
Bridging Anticoagulation
Do not use bridging anticoagulation during the interruption period. 1, 2, 6 The rapid offset and onset of action of apixaban obviates the need for heparin bridging. 1 Bridging increases hemorrhagic risk without reducing thrombotic events and should only be considered in very high thrombotic risk patients after multidisciplinary discussion. 2
Postoperative Resumption
- Low bleeding risk procedures: Resume full-dose Eliquis (5 mg twice daily) at least 24 hours after surgery once adequate hemostasis is established 2, 6
- High bleeding risk procedures: Resume Eliquis 48-72 hours postoperatively; consider reduced dose (2.5 mg twice daily) for the first 2-3 days in high thrombotic risk patients 2, 5
- The initial postoperative dose may be given 12-24 hours after surgery per FDA labeling for orthopedic procedures 6
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, 3
- Do not routinely measure apixaban concentrations when recommended interruption periods are followed 2
- Do not resume therapeutic-dose apixaban in the presence of an epidural catheter 2
- Do not double the dose to make up for a missed dose 6