How long should Eliquis (apixaban) be held before a vasectomy in a patient with Factor V Leiden and a history of thrombophilia?

Perioperative Management of Eliquis for Vasectomy in Factor V Leiden

For a patient with heterozygous Factor V Leiden undergoing vasectomy, hold Eliquis (apixaban) for 48 hours before the procedure. 1

Risk Stratification

Thrombotic Risk Assessment

• Heterozygous Factor V Leiden is classified as "nonsevere coagulopathy" and represents LOW thrombotic risk in the perioperative setting 1
• This mutation alone does not warrant bridging anticoagulation or extended holding periods 1
• The 2024 AHA/ACC guidelines explicitly categorize heterozygous Factor V Leiden (or prothrombin gene G20210A mutation) as a low-risk thrombophilia that does not require special perioperative management beyond standard protocols 1

Bleeding Risk of Vasectomy

• Vasectomy is a low-to-moderate bleeding risk procedure where bleeding would be non-critical in location and easily controlled 1
• This classification allows for shorter preoperative anticoagulation interruption periods 1

Specific Holding Protocol

Preoperative Management

• Hold apixaban for 48 hours (4 doses) before vasectomy 1, 2
• The FDA label states 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
• Given apixaban's half-life of 9-14 hours, 48 hours allows for ≥5 half-lives of drug clearance, ensuring minimal residual anticoagulant effect 1

No Bridging Required

• Do not use bridging anticoagulation during the 48-hour interruption period 1, 2
• The FDA label explicitly states "bridging anticoagulation during the 24 to 48 hours after stopping apixaban and prior to the intervention is not generally required" 2
• Heterozygous Factor V Leiden does not elevate thrombotic risk sufficiently to warrant bridging therapy 1

Postoperative Resumption

Timing of Restart

• Resume apixaban 24-48 hours after vasectomy once adequate hemostasis is achieved 1, 2
• The FDA label recommends restarting "as soon as adequate hemostasis has been established" 2
• For vasectomy specifically, 24 hours post-procedure is typically sufficient given the minor nature of the surgery 1

Important Caveats

When to Extend Holding Period

• If the patient has impaired renal function (CrCl <50 mL/min), consider extending the holding period to 72 hours due to apixaban's 27% renal clearance 1
• If the patient is taking combined P-gp and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir), the effective half-life may be prolonged, warranting discussion with the prescribing physician 2

Factors That Would NOT Change Management

• The presence of heterozygous Factor V Leiden alone does not justify shorter holding periods or immediate resumption 1
• Previous history of VTE >12 months ago would still be classified as low thrombotic risk and would not alter this protocol 1

High-Risk Scenarios Requiring Different Management

• If the patient had VTE within the past 3 months, this would elevate to HIGH thrombotic risk and require consultation with hematology 1
• If the patient is homozygous for Factor V Leiden or has multiple thrombophilias, this constitutes "severe thrombophilia" requiring individualized management 1

Common Pitfalls to Avoid

• Do not hold apixaban for only 24 hours - this provides inadequate drug clearance for procedures requiring complete hemostasis 1
• Do not automatically bridge all patients with Factor V Leiden - heterozygous mutation alone does not warrant this approach and increases bleeding risk 1
• Do not delay resumption beyond 48 hours without specific bleeding concerns - this unnecessarily extends the period of no anticoagulation 2
• Do not confuse heterozygous with homozygous Factor V Leiden - the latter requires substantially different perioperative management 1