What is the maximum duration I can be off Eliquis (apixaban) while having atrial fibrillation requiring anticoagulation?

How Long Can You Stay Off Eliquis with AFib?

You should not intentionally stop Eliquis (apixaban) for atrial fibrillation unless there is a specific medical reason, and any interruption must be carefully managed based on the clinical context—the half-life of apixaban is approximately 12 hours, meaning anticoagulant effect substantially diminishes within 24-48 hours, rapidly increasing stroke risk. 1

Understanding Apixaban Pharmacokinetics

The critical window for stroke risk begins immediately after discontinuation:

• Apixaban has a half-life of approximately 12 hours, meaning therapeutic anticoagulation wanes within 1-2 days of the last dose 1
• Renal elimination accounts for 27% of clearance, with the remainder metabolized hepatically via CYP3A4 1
• After stopping apixaban, anticoagulant protection is essentially lost within 24-48 hours (approximately 2-4 half-lives) 1

Planned Interruption for Surgery or Procedures

Low Bleeding Risk Procedures

For procedures with minor bleeding risk (dental extractions, cataract surgery, superficial dermatologic procedures):

• Stop apixaban 24 hours before the procedure (last dose 24 hours pre-op) 1
• Resume apixaban 6-8 hours after the procedure once hemostasis is secure 1
• No bridging anticoagulation is required for this brief interruption 1

High Bleeding Risk Procedures

For procedures with high bleeding risk (major orthopedic surgery, thoracic/abdominal surgery, spinal anesthesia):

• Stop apixaban 48 hours before the procedure if creatinine clearance >50 mL/min 1
• Stop apixaban 72 hours before the procedure if creatinine clearance 30-50 mL/min 1
• Resume apixaban 48-72 hours after the procedure when bleeding risk has stabilized 1
• Consider prophylactic-dose LMWH starting 6-8 hours post-operatively until full-dose apixaban is resumed 1

Common pitfall: Do not use reduced-dose apixaban (such as VTE prophylaxis doses) in the post-operative period for AF patients—either use prophylactic LMWH or resume full therapeutic apixaban dosing 1

Unplanned Interruption: Stroke Risk Timeline

If apixaban is unintentionally stopped or a patient misses doses:

• Within 12-24 hours: Anticoagulant effect begins declining but some protection remains 1
• 24-48 hours: Anticoagulant protection is substantially lost; stroke risk returns to baseline unprotected levels 1
• Beyond 48 hours: Patient is essentially unprotected, with stroke risk determined by CHA₂DS₂-VASc score 1

The highest stroke risk occurs within the first 72 hours to 10 days after stopping anticoagulation, particularly in the peri-cardioversion setting, but this principle applies to any interruption 1

Cardioversion-Specific Interruption Rules

If cardioversion is planned and apixaban must be interrupted:

• For AF >48 hours or unknown duration: Apixaban must be continued for at least 3 weeks before and at least 4 weeks after cardioversion 1
• Brief interruption for the procedure itself (electrical cardioversion) is acceptable, with resumption immediately after 1
• The 4-week post-cardioversion requirement is mandatory regardless of whether sinus rhythm is maintained, due to atrial stunning 1, 2

What NOT to Do

• Never stop apixaban abruptly without a plan for resumption or bridging, as this creates an unprotected window for thromboembolism 1
• Never assume that maintaining sinus rhythm after cardioversion eliminates the need for anticoagulation—long-term decisions are based on CHA₂DS₂-VASc score, not rhythm 1
• Never use heparin or LMWH as "bridging" in the first 48 hours after acute ischemic stroke, as this increases hemorrhagic transformation risk without benefit 3

Restarting After Interruption

• For elective procedures: Resume apixaban at the standard AF dose (5 mg twice daily, or 2.5 mg twice daily if dose-reduction criteria are met) as soon as adequate hemostasis is achieved 1
• After acute ischemic stroke: Timing depends on stroke severity—mild strokes may allow restart at 3-6 days, severe strokes require waiting 12-14 days 4
• Rivaroxaban must be taken with food for proper absorption in the AF indication; apixaban does not have this requirement 1

Maximum Safe Duration Off Apixaban

There is no "safe" maximum duration to remain off apixaban for a patient with AF requiring anticoagulation—every day without anticoagulation increases cumulative stroke risk proportional to the patient's CHA₂DS₂-VASc score 1. For a patient with CHA₂DS₂-VASc ≥2 (men) or ≥3 (women), the annual stroke risk without anticoagulation ranges from 2.2% to >9%, translating to a daily risk of 0.006% to 0.025% 1. The only acceptable interruptions are those mandated by bleeding risk from procedures, with resumption as soon as medically feasible 1.