When to Stop Eliquis (Apixaban) Prior to Surgery
Stop Eliquis 24 hours (1 day) before low-to-moderate bleeding risk procedures and 48 hours (2 days) before high bleeding risk procedures, with neuraxial procedures requiring 72 hours (3 days) of discontinuation. 1, 2
Procedure Risk Classification
The timing of Eliquis discontinuation depends entirely on the bleeding risk category of your planned surgery:
High Bleeding Risk Procedures (Stop 48 hours before):
- Urologic or GI surgery with anastomosis 1
- Transurethral prostate resection, bladder resection 1
- Nephrectomy, kidney biopsy 1
- Bowel resection 1
- Surgery in highly vascular organs (kidneys, liver, spleen) 1
- Cardiac, intracranial, or spinal surgery 1
- Any major operation lasting >45 minutes 1
- Major cancer or joint replacement procedures 3
Low-to-Moderate Bleeding Risk Procedures (Stop 24 hours before):
- Arthroscopy 1
- Cutaneous/lymph node biopsies 1
- Foot/hand surgery 1
- GI endoscopy with biopsy 1
- Colonoscopy with biopsy 1
- Abdominal hysterectomy 1
- Laparoscopic cholecystectomy 1
- Inguinal hernia repair 1, 3
Minimal Bleeding Risk Procedures (Continue or stop day of procedure):
- Minor dermatologic procedures (skin cancer excision) 1
- Cataract surgery 1
- Minor dental procedures (extractions, fillings) 1
- Pacemaker or defibrillator implantation 1
Special Consideration: Neuraxial Procedures
For epidural anesthesia, spinal anesthesia, or any neuraxial intervention, stop Eliquis for 72 hours (3 days) before the procedure if creatinine clearance is >30 mL/min. 4 This extended interruption period (approximately 6 half-lives) ensures >98% drug elimination and is critical because epidural bleeding can cause devastating lower limb paralysis. 4 Consider extending to 5 days in patients with additional risk factors such as age >80 years or renal impairment. 4
FDA-Approved Timing
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 or where the bleeding would be non-critical in location and easily controlled." 2
Critical Pitfalls to Avoid
Do not use bridging anticoagulation with heparin or low-molecular-weight heparin when stopping Eliquis. 1, 5, 2 The rapid offset and onset of DOACs like Eliquis eliminates the need for bridging, and adding heparin products increases bleeding risk without reducing thrombotic risk. 1, 5
Never perform neuraxial anesthesia if there is any possibility of residual DOAC levels, particularly in elderly patients (>80 years) or those with renal impairment. 4, 5
Renal Function Does Not Affect Timing for Apixaban
Unlike dabigatran, which requires extended interruption periods with renal impairment, apixaban timing remains the same regardless of kidney function (1 day for low-moderate risk, 2 days for high risk) as long as creatinine clearance is >30 mL/min. 1 This is because apixaban has less renal elimination compared to dabigatran. 1
Resuming Eliquis After Surgery
Restart Eliquis at least 24 hours after high bleeding risk procedures and as early as 6 hours after low bleeding risk procedures, once adequate hemostasis is established. 5, 2, 3 For high bleeding risk surgery, delaying 24-48 hours until hemostasis is secure is recommended. 5
If an epidural catheter remains in place, wait at least 2 hours after catheter removal before administering the first dose of Eliquis. 4
Emergency Surgery Considerations
For emergent surgery (<6 hours after presentation) or urgent procedures (6-24 hours), consider reversal agents such as prothrombin complex concentrate (PCC) 50 IU/kg, as bleeding rates can reach up to 23% in these situations. 5, 3 Laboratory testing to measure DOAC levels may be useful to determine whether reversal is needed. 3