From the Guidelines
Patients should take Eliquis (apixaban) for at least 7-10 days after surgery, and extended prophylaxis for up to 4 weeks postoperatively may be offered to patients with high-risk features, such as restricted mobility, obesity, history of VTE, or with additional risk factors, as recommended by the 2023 ASCO guideline update 1. The duration of Eliquis treatment after surgery depends on the type of procedure and individual risk factors.
- For low bleeding risk surgery, Eliquis can be resumed on the day after surgery (24 hours postoperative) at a dose of 5 mg twice daily, as suggested by the 2012 study 1.
- For high bleeding risk surgery, Eliquis can be resumed 2-3 days after surgery (48-72 hours postoperative) at a dose of 5 mg twice daily, with consideration of a reduced dose (2.5 mg twice a day) in patients at high risk for thromboembolism 1. However, the 2023 ASCO guideline update provides more recent and specific guidance on the duration of thromboprophylaxis after surgery, recommending at least 7-10 days of pharmacologic thromboprophylaxis and extended prophylaxis for up to 4 weeks postoperatively for high-risk patients 1. It's essential to take Eliquis exactly as prescribed, at the same times each day, and complete the full course even if you feel better, to minimize the risk of developing dangerous blood clots.
- If you experience unusual bleeding or bruising while taking Eliquis, contact your healthcare provider immediately. Your doctor will prescribe the exact length of treatment based on your specific situation, considering factors like your mobility, history of blood clots, and overall health.
From the FDA Drug Label
The clinical evidence for the effectiveness of apixaban is derived from the ADVANCE-1, ADVANCE-2, and ADVANCE-3 clinical trials in adult patients undergoing elective hip (ADVANCE-3) or knee (ADVANCE-2 and ADVANCE-1) replacement surgery In the ADVANCE-3 study, 5407 patients undergoing elective hip replacement surgery were randomized to receive either apixaban 2. 5 mg orally twice daily or enoxaparin 40 mg subcutaneously once daily. The first dose of apixaban was given 12 to 24 hours post surgery, whereas enoxaparin was started 9 to 15 hours prior to surgery. Treatment duration was 32 to 38 days. In patients undergoing elective knee replacement surgery, apixaban 2. 5 mg orally twice daily was compared to enoxaparin 40 mg subcutaneously once daily (ADVANCE-2, N=3057) or enoxaparin 30 mg subcutaneously every 12 hours (ADVANCE-1, N=3195). In the ADVANCE¬2 study, the first dose of apixaban was given 12 to 24 hours post surgery, whereas enoxaparin was started 9 to 15 hours prior to surgery In the ADVANCE-1 study, both apixaban and enoxaparin were initiated 12 to 24 hours post surgery. Treatment duration in both ADVANCE-2 and ADVANCE-1 was 10 to 14 days.
The recommended duration of Eliquis (apixaban) treatment after surgery is:
- 32 to 38 days for patients undergoing elective hip replacement surgery.
- 10 to 14 days for patients undergoing elective knee replacement surgery 2.
From the Research
Duration of Eliquis (Apixaban) After Surgery
The duration of Eliquis (apixaban) after surgery depends on various factors, including the type of surgery, patient's risk of bleeding and thrombosis, and renal function.
- For elective surgical or nonsurgical procedures, a standardized approach to perioperative apixaban management involves classifying the risk of procedure-related bleeding as minimal, low to moderate, or high risk 3.
- Patients undergoing minimal bleeding risk procedures may continue apixaban, or discontinue it on the day of the procedure if there is concern about excessive bleeding 3.
- For low to moderate bleeding risk procedures, apixaban should be discontinued 1 day before the operation and restarted 1 day after 3.
- For high bleeding risk procedures, apixaban should be stopped 2 days prior to the operation and restarted 2 days after 3.
- The decision to bridge with heparin prior to intervention is not necessary with the new oral anticoagulants, including apixaban, but should be considered on a case-by-case basis, taking into account the patient's individual risk of bleeding and thrombosis 4, 3.
Considerations for Patients with Renal Insufficiency
- Apixaban has been shown to be effective and safe in patients with severe renal failure, with a lower risk of major bleeding and recurrent venous thromboembolism compared to warfarin 5, 6.
- However, the dosage of apixaban may need to be adjusted in patients with renal insufficiency, and close monitoring of renal function and bleeding risk is recommended 5, 6.