How long should a patient with normal kidney function stop taking Eliquis (apixaban) before blepharoplasty?

Stopping Eliquis Before Blepharoplasty

For a patient with normal kidney function undergoing blepharoplasty, stop Eliquis (apixaban) 48 hours before the procedure.

Bleeding Risk Classification

Blepharoplasty is classified as a high bleeding risk procedure because:

• It involves vascular tissue with limited ability to achieve complete hemostasis 1
• Bleeding complications in the periorbital space can cause vision-threatening hematomas 2, 3
• The procedure requires meticulous hemostasis in a confined anatomical space where even minor bleeding can have significant functional consequences 3

Specific Timing for Apixaban Discontinuation

For patients with normal renal function (CrCl ≥80 mL/min):

• Stop apixaban at least 48 hours before blepharoplasty 1
• This means skipping 4 doses (since apixaban is dosed twice daily) 1
• The FDA label confirms discontinuation should occur "at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding" 4

For patients with impaired renal function:

• CrCl 50-79 mL/min: Stop 48 hours before 1
• CrCl 30-49 mL/min: Stop 48 hours before 1
• CrCl 15-29 mL/min: Stop 48 hours before 1

The French guidelines recommend stopping all factor Xa inhibitors (including apixaban) 3 days before high hemorrhagic risk procedures when CrCl is >30 mL/min 1

Critical Management Points

Do NOT use bridging anticoagulation:

• Bridging with LMWH or heparin is not recommended when stopping apixaban 1
• Bridging increases bleeding risk without reducing thrombotic events 1

Timing of resumption:

• Resume apixaban 48-72 hours after the procedure once adequate hemostasis is established 1
• The FDA label states to restart "as soon as adequate hemostasis has been established" 4
• For high bleeding risk procedures like blepharoplasty, waiting closer to 72 hours is prudent 1

Common Pitfalls to Avoid

• Do not rely on standard coagulation tests: INR and aPTT are unreliable for monitoring apixaban levels 1
• Do not use the 24-hour rule: The 24-hour discontinuation window is only appropriate for low bleeding risk procedures, not blepharoplasty 1, 4
• Verify renal function: Always calculate creatinine clearance using the Cockcroft-Gault formula before determining timing 1
• Check for drug interactions: Patients taking concomitant P-glycoprotein inhibitors (dronedarone, amiodarone, verapamil) may need an additional 24 hours of interruption 1

Algorithm Summary

1. Confirm normal renal function (CrCl ≥80 mL/min) 1
2. Stop apixaban 48 hours before surgery (skip 4 doses) 1, 4
3. No bridging anticoagulation 1
4. Perform blepharoplasty with meticulous hemostasis 2, 3
5. Resume apixaban 48-72 hours postoperatively once hemostasis is secure 1