Eliquis for Blood Clot Prevention in an 80-Year-Old Post-Knee Replacement Surgery

Author’s Note: ‘Ben’ is a patient and a long-time family friend. His name and case details have been changed sufficiently to protect Ben’s privacy. Nevertheless, I have obtained Ben’s permission to discuss his recent knee replacement surgery and his use of Eliquis to prevent blood clots.

Key Takeaways

Eliquis offers significant advantages over warfarin in the perioperative setting due to its predictable pharmacokinetics, shorter half-life, and reduced need for monitoring or bridging therapy.

Elderly patients on anticoagulation require careful monitoring for renal function, bleeding risk, and medication adherence

Initiating Eliquis 12 hours after surgery provides effective venous thromboembolism (VTE) prophylaxis with a lower risk of major bleeding complications.

Avoiding concurrent use of NSAIDs or other anticoagulants is critical to minimize bleeding risks in patients taking Eliquis.

Patient education and regular follow-ups are essential to ensure adherence, recognize warning signs of bleeding, and adjust treatment based on renal function and overall health.

Case presentation

Ben came to see me last year with a history of osteoarthritis in his left knee. His medical history includes well-controlled hypertension, managed with amlodipine 5 mg daily, and hyperlipidemia, for which he takes atorvastatin 20 mg daily. He also has a history of atrial fibrillation and had been on anticoagulation therapy; however, we needed to adjust his medication prior to surgery to minimize the risk of excessive bleeding. Ben has no prior history of venous thromboembolism or major bleeding events.

Why Eliquis?

In patients with atrial fibrillation undergoing surgery, selecting the appropriate anticoagulation therapy is critical to balancing the risk of thromboembolism with perioperative bleeding concerns. Traditionally, warfarin has been the standard anticoagulant; however, its requirement for frequent monitoring, dietary restrictions, and variable dosing makes it less ideal in the perioperative setting.

Eliquis (apixaban), a direct oral anticoagulant (DOAC), offers several advantages over warfarin and other vitamin K antagonists in the preoperative period. Unlike warfarin, Eliquis has a predictable pharmacokinetic profile, allowing for more precise anticoagulation management. Its shorter half-life—approximately 12 hours compared to warfarin’s 20–60 hours—enables a more straightforward approach to perioperative discontinuation and resumption. This often eliminates the need for bridging therapy with low-molecular-weight heparin, which can itself increase bleeding risk.

Eliquis is associated with a lower incidence of major bleeding events, including intracranial hemorrhage, making it a safer option, particularly for elderly surgical patients. Clinical studies have demonstrated that DOACs like Eliquis offer a favorable risk-benefit profile, effectively preventing stroke and systemic embolism while reducing the likelihood of major bleeding. Additionally, Eliquis does not require routine INR monitoring, simplifying perioperative management.

For Ben, who was scheduled for knee replacement surgery, switching from traditional anticoagulation therapy such as warfarin to Eliquis provided a safer, more convenient, and effective approach. Its predictable pharmacology, lower bleeding risk, and ease of use made it the preferred option for thromboprophylaxis before and after surgery.

Surgical and postoperative course

Ben underwent a right total knee arthroplasty without intraoperative complications. Blood loss was within the expected range, and he remained hemodynamically stable throughout the procedure. Postoperatively, he received multimodal pain management, including acetaminophen and low-dose opioids. Eliquis was initiated 12 hours after surgery for venous thromboembolism prophylaxis. Early mobilization and physical therapy began on postoperative day one, with steady improvement in ambulation. No signs of deep vein thrombosis or excessive bleeding were observed. By discharge on postoperative day four, Ben demonstrated improved joint mobility and effective pain control, with instructions to continue Eliquis therapy and participate in outpatient rehabilitation.

Monitoring and adherence considerations in an older adult patient

Monitoring and adherence to Eliquis in an older adult patient like Ben requires careful attention to renal function, bleeding risk, and cognitive ability. Regular renal function assessments are crucial, as aging can impair drug clearance. Patients should be monitored for signs of bleeding, including bruising, hematuria, or gastrointestinal symptoms. Medication adherence may be challenging due to memory issues, necessitating the use of pill organizers or caregiver support. Clear patient education on dosing schedules, potential drug interactions, and the importance of continued therapy is essential. Regular follow-ups ensure compliance and allow timely adjustments based on the patient's overall health and mobility status.

Safety considerations

Safety considerations for Ben while taking Eliquis include an increased risk of bleeding due to age-related changes in coagulation, declining renal function, and potential polypharmacy. Older adults are particularly vulnerable to gastrointestinal and intracranial hemorrhages. Regular monitoring of renal function is crucial, as impaired clearance can result in drug accumulation and heightened bleeding risk. Clinicians should educate patients and caregivers on recognizing warning signs such as unexplained bruising, hematuria, or prolonged bleeding. If bleeding occurs, dose adjustments or temporary discontinuation of the medication may be necessary. Additionally, avoiding the concurrent use of NSAIDs or other anticoagulants can help reduce the risk of adverse effects.

If you or a loved one is preparing for joint replacement surgery and currently taking an anticoagulant (blood thinner) for atrial fibrillation, consult your healthcare provider about whether switching to Eliquis before surgery may be a safer and more effective option.

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Sources

Eliquis (apixaban). https://www.eliquis.bmscustomerconnect.com/. Accessed April 10, 2025.
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Sterne JA, Bodalia PN, Bryden PA, et al. Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess. 2017 Mar;21(9):1-386. doi: 10.3310/hta21090.
Agnelli G, Becattini C, Meyer G, et al; Caravaggio Investigators. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med. 2020 Apr 23;382(17):1599-1607. doi: 10.1056/NEJMoa1915103.