In a patient with normal renal function taking apixaban for atrial fibrillation, how long before nasal surgery should the drug be stopped?

Apixaban Discontinuation Before Nasal Surgery

For a patient with normal renal function taking apixaban for atrial fibrillation undergoing nasal surgery, stop apixaban 48 hours (2 days) before the procedure, not 72 hours. 1, 2

Bleeding Risk Classification

Nasal surgery is classified as a high bleeding risk procedure due to the highly vascular nature of the nasal mucosa and the potential for significant hemorrhage. 1

Discontinuation Timeline for Normal Renal Function

For patients with normal renal function (CrCl ≥80 mL/min) undergoing high bleeding risk procedures:

• Stop apixaban 48 hours (2 days) before surgery 1, 3
• This corresponds to approximately 4 half-lives of elimination, resulting in minimal residual anticoagulant effect (approximately 6% or less) 3
• The FDA label specifically states apixaban should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding 2

Why 72 Hours Is Excessive for Normal Renal Function

• 72 hours (3 days) of discontinuation is only indicated for patients with impaired renal function (CrCl 30-49 mL/min) undergoing high-risk procedures 1, 4
• Extending discontinuation beyond 48 hours in patients with normal renal function unnecessarily increases thromboembolic risk without additional bleeding benefit 3
• The most recent American College of Chest Physicians guidelines (2022) explicitly recommend 2 days off for high-bleed-risk procedures in patients with normal renal function 1

Renal Function Considerations

You must verify the patient's renal function before determining the exact discontinuation period:

• CrCl ≥50 mL/min: 48 hours (2 days) 1, 3
• CrCl 30-49 mL/min: 72 hours (3 days) 1, 4
• CrCl 15-29 mL/min: 72 hours minimum, consider anti-Xa level measurement 1, 3

Bridging Anticoagulation

• Do not use bridging anticoagulation with heparin or low molecular weight heparin during the 48-hour interruption 1, 3, 2
• Bridging increases major bleeding risk without reducing stroke or systemic embolism 3

Postoperative Resumption

• Resume apixaban 48-72 hours after nasal surgery once adequate hemostasis is established 1, 4
• Do not restart on the day of surgery due to apixaban's rapid onset of action (peak effect at 3-4 hours) 5
• For the first 2-3 days post-surgery, some experts suggest considering a reduced dose (2.5 mg twice daily) before returning to the full therapeutic dose, though this is not universally recommended 3

Critical Pitfalls to Avoid

• Do not stop only 24 hours before nasal surgery – this provides insufficient clearance (only 2 half-lives) for a high bleeding risk procedure 1, 3
• Do not extend to 72 hours in patients with normal renal function – this increases stroke risk unnecessarily 3
• Do not rely on INR or aPTT to guide timing, as these tests do not reliably reflect apixaban activity 3, 6
• Do not restart full-dose apixaban on the day of surgery – wait until hemostasis is secure 3, 2

When to Consider Anti-Xa Level Measurement

• If renal function is borderline or declining 6
• In elderly patients (≥80 years) with multiple comorbidities 6
• If there is concern about drug accumulation or prolonged half-life 6
• Target apixaban concentration ≤30 ng/mL before proceeding with surgery 7