How to stop Eliquis (apixaban) before surgery?

From the Guidelines

To stop Eliquis (apixaban) before surgery, it is recommended to discontinue the medication 48 hours before the procedure for high bleeding risk surgeries and 24 hours before for low bleeding risk surgeries, taking into account the patient's kidney function and specific surgery risk. When considering the management of anticoagulation in patients undergoing surgery, it's crucial to balance the risk of bleeding against the risk of thromboembolic events. The decision on when to stop Eliquis should be personalized, considering factors such as the type of surgery, the patient's renal function, and their overall risk profile 1. For patients with normal or mildly impaired renal function, stopping Eliquis 48 hours before a high bleeding risk surgery and 24 hours before a low bleeding risk surgery is generally recommended, as this allows for minimal to no residual anticoagulant effect at the time of surgery 1. However, patients with severely impaired renal function (creatinine clearance <30 mL/min) may require a longer duration of pre-operative Eliquis interruption, often 48-72 hours before surgery, due to the longer time required for drug clearance 1. It's also important to note that the management strategy may include measurement of Eliquis levels before surgery, especially in urgent situations or when there's uncertainty about the residual anticoagulant effect, although this approach has its practical limitations and the clinical utility of such tests is still being debated 1. After surgery, Eliquis can typically be restarted 24-72 hours later, once adequate hemostasis is achieved, to minimize the risk of thromboembolic events while avoiding excessive anticoagulation 1. Ultimately, the decision on how to manage Eliquis in the perioperative period should be made in consultation with a healthcare provider, taking into account the latest evidence and guidelines, such as those from the American College of Chest Physicians 1.

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.

To stop Eliquis (apixaban) before surgery, the medication 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, and 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.

From the Research

Stopping Eliquis Before Surgery

To stop Eliquis (apixaban) before surgery, the following guidelines can be considered:

• Apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure 3.
• The median time between the self-reported last dose and presurgery blood sampling was 76 hours for those who achieved concentrations ≤ 30 ng/mL 3.
• Measured anti-Xa activity correlated well with apixaban exposure, indicating that apixaban discontinuation for at least 48 hours is sufficient to minimize the risk of bleeding during surgery 3.

Considerations for Patients with Renal Impairment

For patients with renal impairment, the following considerations should be taken into account:

• Apixaban has been shown to have a lower risk of bleeding compared to conventional anticoagulants in patients with mild renal impairment 4.
• In patients with moderate to severe renal impairment, the risk of bleeding with apixaban is similar to that of conventional anticoagulants 4.
• Apixaban has been associated with a lower risk of major bleeding, intracranial bleeding, and gastrointestinal bleeding compared to warfarin in patients with end-stage kidney disease 5.
• Apixaban has been shown to be effective and safe for the treatment of venous thromboembolism in patients with severe renal failure, with a reduced risk of VTE recurrence and bleeding events 6, 7.

Key Findings

Key findings from the studies include:

• Apixaban discontinuation for at least 48 hours before surgery is sufficient to minimize the risk of bleeding 3.
• Apixaban has a lower risk of bleeding compared to conventional anticoagulants in patients with mild renal impairment 4.
• Apixaban is effective and safe for the treatment of venous thromboembolism in patients with severe renal failure 6, 7.