What is the bleeding risk associated with resection of a bladder tumor and when should Eliquis (apixaban) be held prior to the procedure?

From the Guidelines

For a resection of bladder tumor, Eliquis (apixaban) should typically be held for 48 hours before the procedure, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1. This recommendation balances the bleeding risk associated with the surgery against the risk of thrombotic events from discontinuing anticoagulation. The bleeding risk for bladder tumor resection is considered moderate, as the procedure involves cutting into vascular tissue with potential for significant bleeding, as noted in the American College of Chest Physicians evidence-based clinical practice guidelines 1. After the procedure, Eliquis can usually be resumed 24-48 hours later, once adequate hemostasis is confirmed. However, this timing should be individualized based on your specific thrombotic risk factors. If you have a high thrombotic risk (such as recent venous thromboembolism or mechanical heart valve), your physician might recommend bridging therapy with shorter-acting anticoagulants during the perioperative period, as suggested in the Blood journal article 1. The reason for this careful management is that Eliquis has a half-life of approximately 12 hours and directly inhibits factor Xa in the coagulation cascade, which affects the body's ability to form blood clots. Some key points to consider include:

• The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline provides a framework for managing direct oral anticoagulants (DOACs) like Eliquis in the perioperative period 1.
• The guideline recommends withholding DOACs for a certain period before high-bleeding-risk procedures, such as bladder tumor resection.
• The Blood journal article provides guidance on managing anticoagulated patients undergoing elective procedures or surgery, including the use of bridging therapy 1.
• The American College of Chest Physicians evidence-based clinical practice guidelines highlight the importance of considering the bleeding risk associated with specific procedures, such as urologic surgery 1. Always consult with both your urologist and the physician who prescribed your Eliquis to develop a personalized perioperative anticoagulation plan.

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.

The bleeding risk associated with a resection of bladder tumor is considered moderate to high.

• Hold Eliquis (apixaban) at least 48 hours prior to the procedure. 2

From the Research

Bleeding Risk Associated with Resection of Bladder Tumor

• The bleeding risk associated with resection of bladder tumor is a concern, especially in patients receiving antithrombotic therapy 3, 4.
• Studies have shown that continuous administration of antithrombotic drugs during transurethral resection of bladder tumors (TURBT) is considered safe and useful, as it may prevent serious thromboembolism without adversely affecting the perioperative course 3.
• However, the risk of hemorrhagic complications is higher in patients receiving heparin bridging therapy 4.

Management of Antithrombotic Therapy

• The management of antithrombotic therapy in patients undergoing TURBT is crucial to minimize the risk of bleeding and thromboembolic events 3, 4, 5.
• Studies have shown that preoperative heparin does not increase clinically significant bleeding following TURBT 6.
• The use of antiplatelet therapy, such as acetylsalicylic acid (ASA) and clopidogrel, may affect the outcome of patients undergoing TURBT, with clopidogrel increasing the length of stay 5.

Recommendations

• The decision to hold or continue antithrombotic therapy, including Eliquis, prior to TURBT should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3, 4, 5.
• Patients receiving antithrombotic therapy should be closely monitored for signs of bleeding or thromboembolic events during and after TURBT 3, 4.