see Anticoagulation discontinuation

Apixaban can be omitted for one day before a low/moderate bleeding risk procedure and for two days before a high bleeding risk procedure . Thus, for low/moderate bleeding risk procedures, the patient will omit two dose of apixaban on the one day before the procedure; for high bleeding risk procedures, the patient will omit four doses of apixaban on the two days before the procedure. These intervals are based on an apixaban elimination half-life of 8 to 12 hours. These intervals apply to individuals with normal kidney function or mildly impaired kidney function (CrCl >50 mL/min), who are likely to be receiving the 5 mg twice daily dose; and to those with moderate to severe kidney insufficiency (CrCl 30 to 50 mL/min), who are likely to be receiving the 2.5 mg twice daily dose.

Longer intervals for interruption may be required for situations in which the bleeding risk is very high, such as neuraxial anesthesia.

Routine coagulation tests have not been validated for ensuring that apixaban effect has resolved. A normal or near-normal anti-factor Xa activity level may be used in selected patients to evaluate whether apixaban has been adequately cleared from the circulation prior to surgery (eg, patients at high risk of surgical bleeding). The reliability of anti-factor Xa activity testing may depend on the specific assay used, and clinicians are advised to speak with their clinical laboratory to determine whether this assay is available at their institution and whether it has been validated for direct factor Xa inhibitors.

A 65-year-old man on apixaban 10 mg/day who underwent clipping for a left middle cerebral artery uAN. Apixaban was discontinued 72 h before surgery. During surgery, a thin and pial artery bled slightly at 1 point of the frontal lobe, and hemostasis was easily achieved. Computed tomography (CT) 19 h after surgery showed no evidence of intracranial hemorrhage. He was treated with a heparin-apixaban bridge from 29 h to 41 h after surgery. CT showed a left subarachnoid hematoma 24 h later. ¹⁾.

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