Perioperative Management of Eliquis (Apixaban)

Procedure Risk Classification and Eliquis Discontinuation

• The American College of Chest Physicians recommends stopping Eliquis 24 hours before low-to-moderate bleeding risk procedures and 48 hours before high bleeding risk procedures, with neuraxial procedures requiring 72 hours of discontinuation 1, 2
• High bleeding risk procedures, such as urologic or GI surgery with anastomosis, require stopping Eliquis 48 hours before the procedure 1
• Low-to-moderate bleeding risk procedures, such as arthroscopy or cutaneous/lymph node biopsies, require stopping Eliquis 24 hours before the procedure 1

Special Considerations

• For epidural anesthesia, spinal anesthesia, or any neuraxial intervention, stop Eliquis for 72 hours before the procedure if creatinine clearance is >30 mL/min, to ensure >98% drug elimination 3
• Consider extending the interruption period to 5 days in patients with additional risk factors such as age >80 years or renal impairment 3

Critical Pitfalls to Avoid

• Do not use bridging anticoagulation with heparin or low-molecular-weight heparin when stopping Eliquis, as it increases bleeding risk without reducing thrombotic risk 1, 4
• Never perform neuraxial anesthesia if there is any possibility of residual DOAC levels, particularly in elderly patients (>80 years) or those with renal impairment 3, 4

Renal Function and Eliquis Timing

• Apixaban timing remains the same regardless of kidney function (1 day for low-moderate risk, 2 days for high risk) as long as creatinine clearance is >30 mL/min, due to less renal elimination compared to dabigatran 1, 2

Resuming Eliquis After Surgery

• Restart Eliquis at least 24 hours after high bleeding risk procedures and as early as 6 hours after low bleeding risk procedures, once adequate hemostasis is established 4
• If an epidural catheter remains in place, wait at least 2 hours after catheter removal before administering the first dose of Eliquis 3

Emergency Surgery Considerations

• For emergent surgery or urgent procedures, consider reversal agents such as prothrombin complex concentrate (PCC) 50 IU/kg, as bleeding rates can reach up to 23% in these situations 4

Management of Eliquis for Dental Procedures

Introduction to Eliquis Management

• The European Society of Cardiology recommends holding Eliquis for 24 hours before a dental procedure, as dental work is classified as low bleeding risk 5
• Most routine dental procedures, including extraction of 1-3 teeth, periodontal surgery, and abscess incision, are considered low bleeding risk interventions 6

Risk Classification and Management

• The European Heart Rhythm Association guidelines state that dental surgery can be performed safely with minimal interruption and local hemostatic measures 5
• Adequate local hemostasis can be achieved, and bleeding frequency is low, making dental procedures low bleeding risk 5, 6

Specific Timing and Dosing Considerations

• For patients on Eliquis 5 mg twice daily, the last dose should be taken on the morning of the day before the procedure, providing approximately 24 hours of interruption 7
• For patients on once-daily dosing regimens, the last dose should be taken on the morning of Day -1 if taking morning doses, or on Day -2 evening if taking evening doses 7

Critical Management Points

• The American College of Chest Physicians recommends either continuing vitamin K antagonists with oral prohemostatic agents or stopping 2-3 days before for dental procedures 6, 8
• The European Society of Cardiology recommends not using bridging anticoagulation with heparin or low-molecular-weight heparin when stopping Eliquis for dental work, as it significantly increases bleeding risk without reducing thrombotic risk 5, 9
• Eliquis can be resumed as early as 6 hours after the dental procedure once adequate hemostasis is established 9, 10

Perioperative Management of NOACs in Atrial Fibrillation

Timing of NOAC Discontinuation by Drug and Procedure Bleeding Risk

Classification of Procedure Bleeding Risk

Bridging Anticoagulation

Resumption of NOAC Therapy After Surgery

Practical Instructions and Documentation

Monitoring and Laboratory Considerations

Renal Function Assessment and Drug Interactions

Apixaban Management for Neuraxial Steroid Injections

Pre‑procedure Discontinuation

• The Association of Anaesthetists (Anaesthesia 2013) recommends stopping apixaban 48–72 hours before any spinal or epidural steroid injection to prevent catastrophic spinal epidural hematoma and permanent paralysis. This is a strong guideline recommendation. 13
• For patients with normal renal function (creatinine clearance > 30 mL/min), a minimum interruption of 48 hours is advised; for those with renal impairment or age > 80 years, interruption should be extended to 72–96 hours (up to 5 days) to ensure adequate drug clearance. (Guideline consensus) 13
• The Association of Anaesthetists notes that a 24–48 hour stop interval is sufficient for prophylactic dosing in general procedures, but neuraxial interventions require the longer 48–72 hour window. (Guideline clarification) 13

Bridging Anticoagulation

• Bridging with unfractionated heparin or low‑molecular‑weight heparin when apixaban is held significantly increases bleeding risk and does not reduce thrombotic events. This conclusion is based on moderate‑quality evidence from a 2012 Blood study. 14

Monitoring Drug Clearance

• When uncertainty exists about apixaban clearance, anti‑factor Xa level measurement can be used to assess residual anticoagulant activity, although this assay is not routinely available. (Expert recommendation) 13
• If a traumatic puncture occurs during the neuraxial procedure, the next dose of apixaban should be delayed for at least 48 hours to allow hemostasis. (Safety precaution) 13

Post‑procedure Management

• After a neuraxial injection, apixaban should be re‑started only after adequate hemostasis is confirmed, generally 24–48 hours post‑procedure for low‑risk cases and 48–72 hours for high‑risk neuraxial procedures. (Guideline recommendation) 13

Guideline Consensus and Evidence Base

• The American Society of Regional Anesthesia, the FDA labeling, and multiple international anesthesia societies (as summarized in Anaesthesia 2013) all concur that apixaban must be stopped for neuraxial procedures. This reflects a high‑level, consensus‑based recommendation. 13
• Case reports have documented spontaneous spinal epidural hematomas in patients receiving apixaban, underscoring the severe bleeding risk. (Level IV evidence) 13
• At least one reported case of epidural hematoma occurred despite strict adherence to the recommended anticoagulation interruption, highlighting that even minimal residual drug levels can be hazardous. (Level IV evidence) 13