Apixaban Around Surgery: Hold and Restart Windows

This is a conservative, original summary for clinicians. It aligns with institutional algorithms and neuraxial safety notes. It is not a copy of any guideline table. Confirm local policy before acting.

Quick take

Hold apixaban before surgery based on the bleeding risk of the procedure and renal function. Do not bridge. In neuraxial contexts use stricter timing and hard stops when renal function is reduced.

When to hold apixaban before surgery

Use the procedure risk as your anchor. Low or moderate risk usually needs a shorter hold. High risk or any neurosurgical or neuraxial setting needs a longer hold. Impaired renal function calls for more caution. For very poor renal function, avoid neuraxial techniques with apixaban.

Neuraxial cautions

For epidural, spinal, or intrathecal techniques, escalate holds and apply hard stop thresholds for reduced clearance. If a neuraxial catheter is planned, treat dosing very carefully and avoid apixaban while a catheter is in place.

Catheter gating

If a neuraxial catheter is in place, do not give apixaban. After removal, the earliest dose is removal plus 24 hours. The true restart is the later of the baseline post-op window or removal plus 24 hours.

When to restart apixaban after surgery

Restart only when hemostasis is secure. Low or moderate bleeding risk typically restarts earlier than high risk or neuraxial cases. Use patient factors and the procedural course to guide timing.

Special situations

• Renal impairment: if creatinine clearance is reduced, extend holds conservatively. Very low clearance is a neuraxial hard stop.
• Very high thrombosis risk: do not bridge apixaban. If risk is extreme, consult Hematology for rare exceptions rather than building a bridge plan.

Practical example

Elective high risk procedure with normal renal function. No catheter. Plan a longer pre-op hold and a later restart. If a catheter is placed, keep apixaban off until removal plus 24 hours, then take the later of that time or the baseline post-op window.

Need timestamps that account for renal function and neuraxial steps. Use the AnticoagPlanner calculator to generate a patient specific plan.

FAQ

How long to hold Eliquis before surgery

It depends on bleeding risk and renal function. High risk procedures need a longer hold. Neuraxial cases need the most conservative plan.

When to restart apixaban after surgery

Restart only when hemostasis is secure. High risk and neuraxial settings restart later than low or moderate risk cases.

Can I bridge apixaban

No. DOACs are not bridged. If risk is extreme, discuss rare exceptions with Hematology.

Sources

• MD Anderson. Peri-Procedure Anticoagulants, V8 approved 2025.
• Institutional neuraxial catheter timing summaries derived from ASRA guidance.