When to Discontinue Eliquis Prior to Hysterectomy
For patients undergoing hysterectomy, discontinue Eliquis (apixaban) 48 hours (2 days) before surgery, as hysterectomy is classified as a low-to-moderate bleeding risk procedure requiring some residual anticoagulant effect to be acceptable. 1
Bleeding Risk Classification of Hysterectomy
Abdominal hysterectomy is specifically categorized as a low-to-moderate-bleed-risk surgery with a 30-day risk of major bleeding between 0-2%. 1 This classification is critical because it determines the duration of apixaban interruption needed before the procedure.
Recommended Discontinuation Protocol
Stop apixaban 48 hours (2 days) before the scheduled hysterectomy. 1, 2 This timing allows for approximately 2-3 drug half-lives of interruption, which is appropriate for procedures where some residual anticoagulant effect is acceptable. 1
The FDA label for apixaban confirms this approach, stating that apixaban 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. 2
Supporting Evidence for 48-Hour Hold
Real-world data supports the safety of this approach. A prospective cohort study of 111 patients found that apixaban discontinuation for at least 48 hours before a procedure resulted in clinically insignificant anticoagulation levels, with 94% of patients achieving apixaban concentrations ≤30 ng/mL. 3 The median time between last dose and surgery was 76 hours in patients who achieved safe levels. 3
Key Considerations for High Bleeding Risk Patients
If the patient has additional bleeding risk factors or if the hysterectomy involves particularly high-risk features (such as extensive cancer surgery or anticipated difficult hemostasis), consider extending the hold to 72 hours (3 days) before surgery. 1 The French Working Group on Perioperative Hemostasis recommends this extended interruption for high-bleeding-risk procedures. 1
Bridging Anticoagulation: Not Recommended
Do not use bridging anticoagulation with heparin or low molecular weight heparin when interrupting apixaban for hysterectomy. 1 The rapid offset and onset of action of direct oral anticoagulants like apixaban eliminates the need for perioperative bridging therapy. 1
Resumption After Surgery
Resume apixaban at least 24 hours after hysterectomy, provided there is adequate surgical hemostasis and no ongoing bleeding concerns. 1, 2 For patients with particularly high bleeding risk during the procedure or concerns about hemostasis, consider delaying resumption to 48-72 hours postoperatively. 1
The FDA label specifies that apixaban should be restarted after surgical procedures as soon as adequate hemostasis has been established. 2
Common Pitfalls to Avoid
Do not hold apixaban for only 24 hours before hysterectomy, as this is insufficient for a procedure with moderate bleeding risk. The 24-hour hold is reserved only for minimal-bleed-risk procedures like cataract surgery or minor dental work. 1
Do not routinely measure apixaban levels before surgery, as this is not necessary for standard perioperative management. 1
Do not restart apixaban too early postoperatively. Bleeding complications after hysterectomy, while uncommon (median blood loss 215-660 mL), can occur, and premature anticoagulation resumption increases this risk. 4
Avoid the temptation to bridge with LMWH, as this significantly increases bleeding risk without reducing thrombotic events. 1