How many days to hold Eliquis (apixaban) before surgery?

From the Guidelines

Eliquis (apixaban) should be held for 48 hours before surgery for patients with normal kidney function undergoing low bleeding risk procedures, and for 72 hours before high bleeding risk procedures or for patients with impaired kidney function. The decision on when to hold Eliquis before surgery depends on several factors including the type of surgery, the patient's kidney function, and their individual bleeding risk. According to the most recent guidelines 1, for patients with normal kidney function, withholding DOACs like apixaban for 2 full days (48 hours) before a surgery/procedure should result in minimal to no residual anticoagulant effect at the time of surgery. However, for high bleeding risk procedures or patients with impaired kidney function, a longer duration of 72 hours may be necessary to ensure safety. It's crucial to note that these are general recommendations and the exact timing should be determined by a healthcare provider who can assess the patient's individual risk factors. The healthcare provider can consider factors such as the patient's kidney function, the type of surgery, and the patient's overall health to make an informed decision about when to stop Eliquis. Additionally, it's essential to never stop taking Eliquis without consulting a doctor first, as stopping anticoagulation can increase stroke risk in certain conditions like atrial fibrillation.

Some key points to consider when deciding how long to hold Eliquis before surgery include:

• The type of surgery: high bleeding risk procedures may require a longer duration of Eliquis cessation
• Kidney function: patients with impaired kidney function may require a longer duration of Eliquis cessation
• Individual bleeding risk: patients with a higher bleeding risk may require a longer duration of Eliquis cessation
• The patient's overall health: patients with certain medical conditions may require a longer duration of Eliquis cessation

It's also important to note that the guidelines recommend that no DOAC, including Eliquis, should be taken on the day of the surgery/procedure 1. Ultimately, the decision on when to hold Eliquis before surgery should be made in consultation with a healthcare provider who can assess the patient's individual risk factors and make an informed decision.

From the FDA Drug Label

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 [see Warnings and Precautions (5. 2)] . 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.

The recommended duration to hold Eliquis (apixaban) before surgery is:

• At least 48 hours for elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding.
• At least 24 hours for 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.

From the Research

Apixaban Discontinuation Before Surgery

• The study 3 suggests that apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure.
• The median time between the self-reported last dose and presurgery blood sampling was 76 hours for those who achieved concentrations ≤ 30 ng/mL.
• Measured anti-Xa activity correlated well with apixaban exposure, and clinically significant nonmajor bleeding was reported in one patient at 1 week postsurgery.

Recommendations for Apixaban Discontinuation

• Based on the study 3, it is recommended to hold apixaban for at least 48 hours before surgery to minimize the risk of bleeding.
• However, the optimal duration of apixaban discontinuation may vary depending on individual patient factors and the type of surgery being performed.
• Further studies are needed to confirm these findings and provide more specific guidance on apixaban discontinuation before surgery.

Comparison with Other Anticoagulants

• Studies 4, 5, 6, and 7 compared apixaban with other anticoagulants, such as low molecular weight heparin and warfarin, in various patient populations.
• These studies suggest that apixaban may have a more favorable safety and efficacy profile compared to other anticoagulants in certain situations, but the results are not directly applicable to the question of apixaban discontinuation before surgery.