Should apixaban (Eliquis) be discontinued prior to replacement of an intrathecal pain pump?

From the Guidelines

Eliquis (apixaban) should be discontinued 3 days before a pain pump replacement procedure, as recommended for high-risk procedures in patients on direct oral anticoagulants (DOACs) like apixaban 1. When considering the discontinuation of Eliquis before a pain pump replacement, it's crucial to weigh the risks of bleeding against the risks of thromboembolism. The decision to stop Eliquis should be made in consultation with a healthcare provider, taking into account the patient's specific situation, including kidney function and bleeding risk.

• Key factors influencing the timing of Eliquis discontinuation include:
  • The type of procedure: High-risk procedures, like pain pump replacement, may require longer cessation periods.
  • Kidney function: Patients with reduced renal function may need to stop Eliquis earlier due to the drug's prolonged half-life in such cases.
  • Bleeding risk: The risk of bleeding during and after the procedure must be balanced against the risk of thromboembolic events. According to the guidelines updated by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) in 2021 1, for patients undergoing high-risk procedures, the last dose of rivaroxaban, apixaban, or edoxaban should be taken 3 days before the procedure. This recommendation is supported by the findings of the PAUSE trial, which demonstrated low rates of major bleeding or arterial thromboembolism with standardized interruption of DOAC therapy 1. After the procedure, the healthcare provider will determine when to restart Eliquis, typically within 24-48 hours if there are no bleeding complications, to minimize the risk of thromboembolic events. It's essential not to stop taking Eliquis without consulting a healthcare provider, as discontinuation can increase the risk of blood clots, particularly in patients taking it for conditions like atrial fibrillation or venous thromboembolism. Bridging therapy with shorter-acting anticoagulants may be recommended during the perioperative period to balance these risks.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

Discontinuation of Eliquis (apixaban) is recommended before replacing a pain pump, which can be considered an invasive procedure. The duration of discontinuation depends on the risk of bleeding associated with the procedure.

• For procedures with a moderate or high risk of bleeding, discontinue Eliquis at least 48 hours prior to the procedure 2.
• For procedures with a low risk of bleeding, discontinue Eliquis at least 24 hours prior to the procedure 2.

From the Research

Discontinuation of Eliquis Before Pain Pump Replacement

• The decision to discontinue Eliquis (apixaban) before a pain pump replacement procedure should be based on a comprehensive assessment of the patient's risk factors and the potential benefits and risks of discontinuing anticoagulant therapy 3.
• There is good evidence that discontinuation of anticoagulant therapy with apixaban prior to interventional techniques increases safety, but this decision should be made on an individual basis, taking into account the patient's pharmacokinetics and pharmacodynamics, as well as their individual risk factors 3.
• The risk of thromboembolic events is higher than the risk of epidural hematoma formation when anticoagulant therapy is interrupted before interventional procedures, but both risks are significant 3.
• If the thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during the cessation of anticoagulant therapy, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure 3.
• The use of apixaban has been studied in various clinical trials, and it has been shown to be effective in the treatment and prevention of venous thromboembolism, with a lower risk of major bleeding compared to other anticoagulants 4, 5.
• However, there are some populations in which the use of apixaban has not been extensively studied, such as patients over 75 years old, or those with cancer, low or high body weight, or poor renal function 5.
• In patients undergoing common interventional pain procedures, continuing or discontinuing anticoagulants has been associated with different risks, and the decision to discontinue anticoagulants should be made on a case-by-case basis, taking into account the patient's individual risk factors and the potential benefits and risks of discontinuing anticoagulant therapy 6.
• In the event of uncontrollable bleeding after treatment with apixaban, a specific agent to reverse factor Xa inhibition, such as andexanet alfa, may be clinically indicated, especially in cases where the patient has received a dose of apixaban less than 12 hours earlier or in the event of a catastrophic bleed 7.