What are the guidelines for discontinuing Eliquis (apixaban) prior to a hysterectomy?

From the Guidelines

If you are taking Eliquis (apixaban) and planning for a hysterectomy, you should typically stop taking it 48 hours before the surgery, as recommended by the most recent guidelines 1. For patients with normal kidney function, this 2-day window allows the medication to clear from your system sufficiently to reduce bleeding risk during surgery. However, if you have reduced kidney function, your doctor may recommend stopping it 72 hours (3 days) before surgery, as suggested by the American College of Chest Physicians clinical practice guideline 1. After surgery, Eliquis can usually be resumed 24-48 hours later, once your surgeon confirms adequate hemostasis has been achieved. This timing is critical because Eliquis is an anticoagulant that prevents blood clot formation by inhibiting Factor Xa in the coagulation cascade. Stopping too early could increase risk of blood clots, while stopping too late could lead to excessive surgical bleeding. Never stop Eliquis without specific instructions from your healthcare provider, as the exact timing depends on your personal risk factors, the type of hysterectomy being performed, and your overall health status. Your surgeon and the doctor who prescribed Eliquis should coordinate this plan together, considering the latest guidelines from the American Heart Association 1. Some key points to consider include:

• The type of surgery and its associated bleeding risk
• Your kidney function and how it may affect the clearance of Eliquis
• The need for coordination between your healthcare providers to ensure safe management of your anticoagulation therapy
• The importance of measuring coagulation parameters or drug levels to assess the risk of bleeding or thrombosis, as recommended by the latest guidelines 1. It is essential to follow the most recent and highest quality guidelines, such as those from the American Heart Association 1, to minimize the risk of morbidity, mortality, and to improve the quality of life.

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 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. Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.

Stopping apixaban (Eliquis) for hysterectomy: The recommended duration for stopping apixaban before a surgical procedure depends on the risk of bleeding associated with the procedure. For a hysterectomy, which is considered a procedure with a moderate to high risk of bleeding, apixaban should be discontinued at least 48 hours prior to the procedure. Apixaban can be restarted after the procedure as soon as adequate hemostasis has been established 2.

From the Research

Stopping Eloquis for Hysterectomy

• There are no direct studies on stopping Eloquis (apixaban) for hysterectomy. However, studies on apixaban discontinuation for invasive or major surgical procedures provide some insights 3.
• A prospective cohort study found that apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure 3.
• Another study compared apixaban with enoxaparin for preventing postoperative venous thromboembolism in women undergoing surgery for gynecologic malignant neoplasm, and found that apixaban was a potentially safe, less painful, and easier-to-take alternative to subcutaneous enoxaparin for thromboprophylaxis after surgery for gynecologic cancer 4.
• The safety and efficacy of apixaban versus low-molecular weight heparin or vitamin-K antagonists for venous thromboembolism treatment in patients with severe renal failure have also been studied, and apixaban was found to be favored over warfarin for treating VTE in severe renal failure, reducing VTE recurrence and bleeding risk 5.
• A study on heparin bridging therapy in patients on long-term oral anticoagulants found that low-molecular-weight heparin (LMWH) was used substantially more often than unfractionated heparin (UFH) as bridging therapy, and that overall adverse events, including thromboembolism and bleeding, were similar for patients treated with LMWH or UFH 6.
• The optimal method for heparin bridging therapy has not been established, and no large prospective studies have compared UFH with LMWH for the perioperative management of patients at risk of thromboembolism requiring temporary interruption of long-term OAC therapy 6.