Does the patient need to discontinue Eliquis (apixaban) prior to therapeutic recurrent paracentesis, and if so, for how many days?

From the Guidelines

Eliquis (apixaban) should be discontinued at least 48 hours before a therapeutic paracentesis to minimize bleeding risk, as recommended by the most recent and highest quality study 1. For patients with normal renal function, 48 hours is generally sufficient, while those with impaired kidney function may need the full 72 hours due to delayed drug clearance. The timing depends on the patient's specific bleeding risk factors, renal function, and the urgency of the procedure. After the paracentesis, Eliquis can usually be resumed 24-48 hours later if hemostasis is adequate and there are no signs of bleeding complications. This recommendation balances the risk of bleeding during the procedure against the risk of thrombotic events while off anticoagulation. Some key points to consider include:

• The interruption of DOACs before an elective surgery/procedure can follow a pharmacokinetic-based approach, as used with the perioperative management of other anticoagulants 1.
• For patients having a high-bleed-risk surgery/procedure, withholding DOACs for 2 full days before the procedure is recommended, while for patients having a low-to-moderate-bleed-risk surgery/procedure, withholding DOACs for 1 full day before the procedure may be sufficient 1.
• The American College of Chest Physicians clinical practice guideline recommends a pharmacokinetic-based approach for the perioperative management of antithrombotic therapy, including DOACs 1.
• Other studies, such as the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guideline update 1 and the 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy 1, also provide guidance on the management of DOACs in patients undergoing procedures, but the most recent and highest quality study 1 should be prioritized. For patients at very high thrombotic risk, bridging with shorter-acting anticoagulants might be considered, though this should be determined on a case-by-case basis. Always consult with both the proceduralist performing the paracentesis and the provider who prescribed the anticoagulant to develop the optimal management plan for your specific patient.

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 The patient needs to be off Eliquis (apixaban) at least 48 hours prior to the therapeutic recurrent paracentesis, if it is considered an invasive procedure with a moderate or high risk of unacceptable or clinically significant bleeding 2.

From the Research

Apixaban Discontinuation Prior to Paracentesis

• The decision to discontinue apixaban prior to paracentesis depends on various factors, including the patient's renal function and the risk of bleeding 3.
• A study published in 2023 reported two cases of severe bleeding complications after paracentesis in patients with compensated cirrhosis and moderate renal impairment who were taking apixaban, suggesting that paracentesis may not be a low bleeding-risk procedure in these patients 3.
• Another study published in 2024 found that apixaban has a favorable clinical efficacy and safety profile compared to vitamin K antagonists for patients with atrial fibrillation or venous thromboembolism and comorbid kidney impairment 4.
• A prospective cohort study published in 2022 found that discontinuing apixaban for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure 5.

Recommendations for Apixaban Discontinuation

• Based on the available evidence, it is recommended that apixaban be discontinued for at least 48 hours prior to paracentesis to minimize the risk of bleeding complications 5.
• However, the decision to discontinue apixaban should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.
• Further studies are needed to determine the optimal duration of apixaban discontinuation prior to paracentesis and to establish clear guidelines for the management of patients taking apixaban who require paracentesis.

Eliquis (Apixaban) and Paracentesis

• Eliquis is another name for apixaban, and the same considerations apply to its use prior to paracentesis.
• The studies mentioned above provide evidence on the safety and efficacy of apixaban, which can be applied to the use of Eliquis in patients undergoing paracentesis 3, 4, 5.