How long should a patient taking Eliquis (apixaban) stop and restart the medication before and after a robotic hysterectomy?

Perioperative Management of Eliquis for Robotic Hysterectomy

Stop Eliquis 48 hours before robotic hysterectomy and restart 24-48 hours after surgery once adequate hemostasis is established. 1, 2, 3

Preoperative Discontinuation

Robotic hysterectomy is classified as a high bleeding risk procedure, requiring 48 hours of Eliquis discontinuation before surgery. 1, 2, 3

Standard Timing (Normal Renal Function)

• Last dose should be taken 48 hours (2 days) before surgery for patients with CrCl ≥50 mL/min 1, 2
• This corresponds to approximately 4 doses skipped for the standard 5 mg twice-daily regimen 1
• The FDA label specifically states discontinuation at least 48 hours prior to elective surgery with moderate or high risk of bleeding 3

Adjusted Timing for Renal Impairment

• For patients with CrCl 30-49 mL/min (moderate impairment): extend discontinuation to 72 hours (3 days) before surgery 1, 4
• For patients with CrCl 15-29 mL/min: extend discontinuation to 48 hours minimum, though some guidelines suggest up to 72 hours 1
• Unlike dabigatran, apixaban timing is less affected by renal function due to lower renal elimination, but caution is still warranted 2

Special Considerations for Neuraxial Anesthesia

• If spinal or epidural anesthesia is planned, stop Eliquis for 72 hours (3 days) before the procedure 2, 4
• This ensures >98% drug elimination and minimizes risk of spinal hematoma 2
• Never perform neuraxial anesthesia with any possibility of residual DOAC levels, particularly in elderly patients (>80 years) or those with renal impairment 2

Additional Risk Factors Requiring Extended Hold

• Consider extending the interruption period to 4-5 days in patients with:
  • Age >80 years 2
  • Concurrent use of P-glycoprotein or strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir) 4
  • Body weight ≤60 kg 3
  • Serum creatinine ≥1.5 mg/dL 3

Critical Management Points

No Bridging Anticoagulation

Do not use bridging with heparin or low-molecular-weight heparin when stopping Eliquis. 1, 2, 4

• Bridging significantly increases bleeding risk without reducing thrombotic events 1, 2
• The predictable pharmacokinetics of apixaban allow safe short-term cessation 1

Renal Function Assessment

Always calculate creatinine clearance using the Cockcroft-Gault formula before determining hold duration. 4

• This is essential as renal impairment prolongs drug clearance 1, 4

Postoperative Resumption

Restart Eliquis at least 24 hours after robotic hysterectomy, once adequate hemostasis is confirmed. 1, 2, 3

Standard Resumption Protocol

• For high bleeding risk procedures like hysterectomy: resume 24-48 hours postoperatively 1, 2
• The European Heart Rhythm Association recommends 48-72 hours for high bleeding risk interventions 1
• The FDA label states to restart "as soon as adequate hemostasis has been established" 3

Epidural Catheter Considerations

• If an epidural catheter remains in place, wait at least 2 hours after catheter removal before administering the first dose of Eliquis 2

Clinical Assessment Before Resumption

• Confirm surgical site hemostasis visually and clinically 2, 3
• Assess for any ongoing bleeding or hematoma formation 2
• Consider delaying resumption up to 48-72 hours if there are concerns about bleeding risk 1, 2

Common Pitfalls to Avoid

• Do not assume 24 hours is sufficient—robotic hysterectomy requires 48 hours minimum for standard patients 1, 2, 3
• Do not forget to assess renal function—impaired clearance necessitates longer hold times 1, 4
• Do not bridge with heparin—this increases bleeding without benefit 1, 2, 4
• Do not resume Eliquis too early—confirm hemostasis before restarting 2, 3
• Do not ignore drug interactions—P-gp and CYP3A4 inhibitors require extended hold periods 4
• Do not perform neuraxial anesthesia without ensuring 72-hour discontinuation 2, 4

Bleeding Risk Context for Robotic Hysterectomy

While robotic hysterectomy is generally associated with lower blood loss than open procedures (median 60-99 mL), it remains a high bleeding risk procedure due to the potential for vascular injury and the clinical impact of bleeding in the surgical field. 5, 6