When to start Eliquis (apixaban) after surgery?

When to Start Eliquis (Apixaban) After Surgery

Resume apixaban at least 24 hours after surgery once adequate hemostasis is established, with timing extended to 48-72 hours for high bleeding risk procedures. 1

Timing Based on Surgical Bleeding Risk

Low-to-Moderate Bleeding Risk Surgery

• Resume apixaban 24 hours after surgery (on the day after surgery) at full therapeutic dose 1
• Examples include: laparoscopic cholecystectomy, abdominal hernia repair, arthroscopy, colonoscopy with biopsy, pacemaker implantation 1
• No bridging anticoagulation is needed due to apixaban's rapid onset of action 1

High Bleeding Risk Surgery

• Delay resumption to 48-72 hours after surgery (2-3 days postoperatively) 1
• Examples include: major orthopedic surgery, thoracic surgery, abdominal surgery, cardiac surgery, intracranial/spinal surgery, neuraxial anesthesia procedures 1
• For patients at high thrombotic risk undergoing major surgery, consider starting with a reduced dose (apixaban 2.5 mg twice daily) for the first 2-3 days, then increase to full therapeutic dose 1

Minimal Bleeding Risk Procedures

• Continue apixaban without interruption or resume immediately after the procedure 1, 2
• Examples include: minor dental procedures, minor dermatologic procedures, cataract surgery 1

Special Considerations for Orthopedic Surgery

Hip or Knee Replacement Surgery (VTE Prophylaxis)

• Start apixaban 2.5 mg twice daily 12-24 hours after surgery 3, 4
• Continue for 35 days after hip replacement 4, 5
• Continue for 12 days after knee replacement 4, 5
• This is a prophylactic dose, not therapeutic anticoagulation 4

Alternative Bridging Strategy (If Immediate Anticoagulation Needed)

If VTE prophylaxis is required immediately postoperatively before apixaban can be safely resumed:

• Administer heparin or fondaparinux at least 6 hours after surgery 3, 6
• Then transition to apixaban once hemostasis is adequate (typically 24-48 hours) 6
• Do not use bridging anticoagulation routinely as it increases bleeding risk without reducing thrombotic complications 6, 2

Key Factors Affecting Timing

Patient-Specific Factors Requiring Delayed Resumption

• Renal impairment (CrCl < 50 mL/min): Consider extending delay beyond standard 48 hours 1, 6
• Age ≥ 80 years: May require longer interruption and delayed resumption 6
• Body weight < 60 kg: Monitor more closely for bleeding 4
• Concomitant P-glycoprotein or CYP3A4 inhibitors: Increases apixaban levels 4, 7

Surgical Factors

• Extent of surgical dissection and tissue trauma 1
• Presence of epidural catheter: Special timing considerations apply; coordinate with anesthesia 3, 6
• Ongoing bleeding or inadequate hemostasis: Delay resumption until bleeding controlled 1, 4

Critical Pitfalls to Avoid

• Never resume full-dose apixaban too early after high bleeding risk surgery (within 24 hours), as this significantly increases major bleeding risk 1
• Do not routinely use heparin bridging when restarting apixaban, as this increases hemorrhagic complications without reducing thrombotic events 6, 2
• Do not double the dose if a dose is missed; simply resume the regular schedule 4
• Avoid overlapping anticoagulants when transitioning between agents to prevent excessive anticoagulation 3
• Monitor renal function postoperatively, as surgical stress may affect kidney function and apixaban clearance 3, 6

Practical Algorithm for Resumption

1. Assess surgical bleeding risk (minimal, low-moderate, or high) 1
2. Verify adequate hemostasis at surgical site 1, 4
3. Check renal function postoperatively 6
4. For low-moderate risk: Resume at 24 hours with full dose 1
5. For high risk: Wait 48-72 hours; consider reduced dose initially if high thrombotic risk 1
6. If epidural catheter present: Coordinate timing with catheter removal per anesthesia guidelines 3, 6