Apixaban pharmacokinetic properties and some clinical reports suggest cessation 48 hours prior to surgery is safe, but this has not been demonstrated in a naturalistic setting. We sought to measure the residual apixaban exposure in patients who had apixaban held as part of standard of care peri-operative management.
This was a prospective, observational study of patients in whom apixaban plasma concentration and anti-Xa activity were measured while at steady state apixaban dosing and again immediately prior to surgery. Clinical management of cessation and resumption of apixaban was at the discretion of the treating physician.
One hundred and eleven patients provided paired blood samples. Ninety four percent (104/111) patients had measured apixaban concentrations of < 30 ng/mL. Only one patient had a value > 50 ng/mL. The median time between the self-reported last dose and pre-surgery blood sampling was 76 hours (range 32 – 158) for those who achieved concentrations < 30 ng/mL and 59 hours (range 49 – 86) for those > 30 ng/mL. Measured anti-Xa activity correlated well with apixaban exposure. Clinically significant non-major bleeding was reported in one patient at 1-week post-surgery. There was one venous thromboembolic event and one stroke in the peri-operative period.
In a naturalistic setting with a heterogeneous patient population, apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure. (NCT02935751)
Merli, Geno J.; Kraft, Walter K.; Eraso, Luis H.; Galanis, Taki; Thomson, Lynda J.; Ouma, Geoffrey O.; Viscusi, Eugene; Gong, Jerald Z.; and Lam, Edwin, "Apixaban Discontinuation for Invasive Or major Surgical procedures (ADIOS): A prospective cohort study." (2021). Department of Medicine Faculty Papers. Paper 315.