Management of Apixaban in Patients with Recent Cervical Fusion

Perioperative Management

For patients who had cervical fusion, considered a procedure with high bleeding risk, apixaban should be restarted with caution, based on the surgical bleeding risk assessment, as recommended by the American Society of Anesthesiologists 1, 2
Wait at least 24-72 hours after surgery before restarting therapeutic anticoagulation to ensure adequate surgical hemostasis, with a strength of evidence level of moderate, according to the American College of Chest Physicians 3, 4
If venous thromboprophylaxis is indicated before full anticoagulation can be safely restarted, consider using prophylactic doses of heparin or LMWH starting at least 6 hours after the end of surgery, as suggested by the American Society of Anesthesiologists 3, 4

For procedures with high bleeding risk like cervical spine surgery, resume apixaban the next morning if morning dose, or the evening of the next day if evening dose, for once-daily regimens, as recommended by the American Society of Anesthesiologists 3
For twice-daily regimens, resume apixaban the next day, not the same day as surgery, with a strength of evidence level of high, according to the American College of Chest Physicians 3, 4
Full therapeutic anticoagulation should typically be resumed 24-72 hours postoperatively, only after confirming surgical hemostasis, as recommended by the American Society of Anesthesiologists 1, 4

If an epidural catheter was placed for pain control, therapeutic anticoagulation must be delayed until after catheter removal, as recommended by the French Working Group on Perioperative Hemostasis 1, 3
The French Working Group on Perioperative Hemostasis strongly recommends against performing spinal or epidural procedures in patients with possible residual apixaban effect, with a strength of evidence level of high 1, 4

Monitor renal function postoperatively as surgical procedures may affect kidney function and potentially alter apixaban clearance, as suggested by the American Society of Anesthesiologists 4
Avoid apixaban in patients with severe renal impairment (CrCl <15 mL/min), as recommended by the National Comprehensive Cancer Network 5
Use with caution in patients with hepatic impairment (transaminases >2 times upper limit of normal or total bilirubin >1.5 times upper limit of normal), as recommended by the National Comprehensive Cancer Network 5, 6