How long should Eliquis (apixaban) be held prior to a vasectomy in a male patient with a history of atrial fibrillation, deep vein thrombosis, or pulmonary embolism, considering renal function and bleeding risk factors?

Eliquis Management for Vasectomy

For vasectomy procedures, hold Eliquis (apixaban) for 48 hours (2 days) prior to the procedure, with the last dose taken 2 full days before surgery. 1, 2

Procedure Risk Classification

Vasectomy is classified as a high bleeding risk procedure due to:

• Vascular tissue manipulation in a confined space 1
• Difficulty achieving hemostasis if bleeding occurs 3
• Risk of hematoma formation that can compromise surgical outcomes 4

Specific Timing Recommendations

Standard dosing (5 mg twice daily):

• Last dose should be taken 48 hours before the procedure 1, 2
• This means skipping 4 doses total (2 full days of twice-daily dosing) 1
• Provides 4-5 half-lives of drug elimination, resulting in minimal residual anticoagulant effect 1

Renal function considerations:

• For patients with normal renal function (CrCl >50 mL/min): 48-hour hold is sufficient 1
• For patients with moderate renal impairment (CrCl 30-50 mL/min): extend to 72 hours (3 days) before the procedure 1
• Apixaban has less renal elimination (27%) compared to dabigatran, so timing is less affected by mild renal impairment 5

Critical Management Points

Do NOT use bridging anticoagulation:

• Bridging with heparin or low-molecular-weight heparin significantly increases bleeding risk without reducing thrombotic risk 3, 4
• The FDA label specifically states bridging is "not generally required" during the 24-48 hour interruption period 2

Resumption after vasectomy:

• Restart Eliquis at least 24 hours after the procedure once adequate hemostasis is established 3, 2
• For high bleeding risk procedures like vasectomy, waiting 24-48 hours is appropriate 4
• Resume at the patient's usual maintenance dose 2

Common Pitfalls to Avoid

Age and additional risk factors:

• In patients >80 years old, consider extending the interruption period to 72 hours (3 days) 3
• Apixaban has a half-life of approximately 12 hours, so 48 hours provides 4 half-lives of elimination in most patients 5

Timing calculation:

• The 48-hour period represents 2 full days where no doses are taken, plus the day of surgery 1
• Example: If surgery is Monday at 8 AM, last dose should be Saturday morning 1

Verification of adequate washout:

• Unlike warfarin, no laboratory monitoring (INR) is needed to confirm adequate drug elimination 2, 6
• The fixed timing based on half-life elimination is sufficient 1, 3