How long should Eliquis (apixaban) be held before an elective procedure in a patient with normal kidney function and a history of atrial fibrillation?

How Long to Hold Eliquis Before a Procedure

For patients with normal kidney function undergoing elective procedures, stop Eliquis 24 hours before low-bleeding-risk procedures and 48 hours before high-bleeding-risk procedures. 1

Procedure Risk Classification

The bleeding risk of your planned procedure determines the timing of Eliquis discontinuation:

Low-to-Moderate Bleeding Risk Procedures

• Stop Eliquis 24 hours before the procedure (skip 2 doses) 2, 3, 1
• Examples include: arthroscopy, coronary angiography, GI endoscopy with biopsy, cutaneous/lymph node biopsies, abdominal hernia repair, and most dental procedures 2, 3, 4
• The FDA label specifically states to discontinue at least 24 hours prior to elective surgery or invasive procedures with low bleeding risk 1

High Bleeding Risk Procedures

• Stop Eliquis 48 hours before the procedure (skip 4 doses) 2, 3, 1
• Examples include: major operations lasting >45 minutes, cardiac surgery, intracranial or spinal surgery, surgery in highly vascular organs, urologic or GI surgery with anastomosis 2, 3, 4
• The FDA label mandates discontinuation at least 48 hours prior to procedures with moderate or high risk of unacceptable or clinically significant bleeding 1

Neuraxial Procedures (Special Category)

• Stop Eliquis 72 hours before epidural anesthesia, spinal anesthesia, or any neuraxial intervention 3
• This extended period ensures >98% drug elimination and is critical to avoid catastrophic spinal hematoma 3
• Never perform neuraxial anesthesia if there is any possibility of residual drug levels, particularly in elderly patients (>80 years) or those with renal impairment 3

Renal Function Considerations

For patients with normal or mildly impaired renal function (CrCl ≥50 mL/min), the timing remains the same as above because apixaban has less renal elimination compared to dabigatran 3, 4

Moderate Renal Impairment (CrCl 30-50 mL/min)

• Low-bleeding-risk procedures: Stop 3 days before (skip 4 doses) 2, 4
• High-bleeding-risk procedures: Stop 4 days before (skip 6 doses) 2, 4

Severe Renal Impairment (CrCl 15-29 mL/min)

• Low-bleeding-risk procedures: Stop at least 36 hours before 2, 4
• High-bleeding-risk procedures: Stop at least 48 hours before 2

Critical Management Points

Do NOT Use Bridging Anticoagulation

• Bridging with heparin or low-molecular-weight heparin is NOT recommended when stopping Eliquis 3, 4, 1
• The predictable waning of anticoagulation effect allows properly timed short-term cessation without bridging 2
• Mixing two anticoagulants significantly increases bleeding risk without reducing thrombotic risk 3, 4

Additional Risk Factors Requiring Extended Interruption

• Consider extending the interruption period to 5 days in patients with: 3
  • Age >80 years
  • Additional renal impairment beyond baseline
  • Procedures involving the cervical spine
  • Multiple procedural attempts anticipated
  • Large bore needles required

Resuming Eliquis After Surgery

• Low-bleeding-risk procedures: Resume as early as 6 hours after the procedure once adequate hemostasis is established 3, 1
• High-bleeding-risk procedures: Resume at least 24-48 hours after surgery, or up to 48-72 hours for very high-risk procedures 3, 4, 1
• If an epidural catheter remains in place, wait at least 2 hours after catheter removal before administering the first dose 3

Common Pitfalls to Avoid

• Never double the dose to make up for a missed dose during the interruption period 1
• Do not rely on INR testing during the transition period, as apixaban affects INR measurements 1
• Avoid performing procedures if there is uncertainty about the last dose timing or residual drug levels, especially for neuraxial procedures 3
• Do not assume all procedures are the same risk—verify the bleeding risk classification with your surgeon before determining the interruption period 2, 3