How long to stop Apixaban for optimal concentration before surgery

According to the results of clinical trials published in Vascular medicine.

Discontinuation of Apixaban for Invasive or Major Surgical Procedures (ADIOS) ( ID: NCT02935751) was a prospective single-site observational study conducted at Thomas Jefferson University between 2016 and 2018. Patients (N = 130) receiving apixaban for non-valvular atrial fibrillation or venous thromboembolism (VTE) and who required major or elective invasive surgery were advised to stop using apixaban before surgery. Doctors decided when to advise patients to stop use based on the plasma concentrations of apixaban and anti-Xa activity. Bleeding and major adverse cardiac events were assessed up to day 30.

The patients had a mean age of 68.6 ± 11.6 years; 52% were women; the median body mass index (BMI) was 30 (range, 21-52); 80.6% were white; 59% used apixaban because of a stroke, transient ischemic attack, or risk of systemic embolism; 25% due to the risk of venous thromboembolic recurrence; and 9% for multiple indications.

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Prior to surgery, 93.7% had apixaban concentrations less than or equal to 30 ng / mL. The median time since the last dose of apixaban was 75.5 hours for the 30 ng / mL or less cohort and 59.3 hours for the 30 ng / mL cohort. All patients below or equal to 30 ng / mL were on a maintenance regimen of 5 mg twice daily.

A total of 18 events occurred during follow-up, including any major adverse cardiac event (n = 5), arrhythmia (n = 3), infection (n = 3), stroke (n = 1), bleeding non-major (n = 1), thromboembolic event (n = 1) and other (n = 9). These events occurred during the first week (n = 7) or weeks 2-4 (n = 9).

This study was limited by the provider-directed shutdown protocol and the resulting wide range of shutdown windows.

“A large proportion of patients (93.7%; 95% CI: 88-97%) achieved apixaban plasma concentrations of [greater than or equal to] 30 ng / mL after at least 48 hours off, ”noted the study authors. “A greater proportion (> 90%) of patients achieved less than 30 ng / mL when apixaban was discontinued for [greater than] 60 hours. The clinical evidence here supports current pharmacokinetic discontinuation strategies based on patient factors and the half-life of apixaban.

Disclosure: One author has declared affiliations with the industry. Please refer to the original article for a full list of disclosures.


Merli GJ, Kraft WK, Eraso LH et al. Discontinuation of Apixaban for Invasive or Major Surgery (ADIOS): A Prospective Cohort Study. Vasc Med. 2021; 1358863X211047270. doi: 10.1177 / 1358863X211047270

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