Should I discontinue Apixaban (Eliquis) prior to facet joint injections?

From the Guidelines

You should not stop apixaban prior to facet joint injections, as the 2018 European Heart Rhythm Association practical guide recommends not interrupting oral anticoagulation for most minor surgical procedures where bleeding is easily controllable 1. When considering facet joint injections, it's essential to weigh the risks of bleeding against the risks of thromboembolic events.

• The decision to continue or stop apixaban should be made in consultation with your healthcare provider, taking into account your individual bleeding risk factors and kidney function.
• According to the 2018 European Heart Rhythm Association practical guide, minor surgical procedures like facet joint injections can be performed 12–24 h after the last NOAC intake, and then restart 6 h later, skipping one dose of dabigatran or apixaban 1.
• It's crucial to follow your doctor's instructions and not stop apixaban without explicit guidance, as discontinuing this blood thinner can increase your risk of blood clots, especially if you take it for atrial fibrillation or venous thromboembolism.
• Your doctor will assess your specific medical situation and provide personalized recommendations for managing apixaban during the procedure, including any necessary "bridging" strategies to minimize bleeding and clotting risks.
• After the procedure, your doctor will advise when to safely resume apixaban, typically within 24 hours if there are no complications, as recommended by the 2018 European Heart Rhythm Association practical guide 1.

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.

Stopping Apixaban Prior to Facet Joint Injections:

• Facet joint injections are considered invasive procedures.
• The risk of bleeding associated with facet joint injections is generally considered moderate.
• Based on the information provided, it is recommended to discontinue apixaban tablets at least 48 hours prior to facet joint injections 2.

From the Research

Stopping Apixaban Prior to Facet Joint Injections

• The decision to stop apixaban prior to facet joint injections depends on various factors, including the patient's individual risk of bleeding and thromboembolism 3.
• A study published in 2022 found that stopping apixaban for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure 3.
• However, another study published in 2012 found that arthrocentesis and joint injections can be safely performed in patients receiving anticoagulation at therapeutic levels, without the need to reduce the level of anticoagulation before procedures 4.
• The safety of stopping apixaban prior to facet joint injections is not well-established, and more research is needed to determine the optimal management strategy 5, 6, 7.
• It is essential to weigh the risks and benefits of stopping apixaban prior to facet joint injections on a case-by-case basis, taking into account the patient's individual risk factors and medical history 3, 4.

Key Considerations

• The patient's risk of bleeding and thromboembolism should be carefully assessed before making a decision to stop apixaban 3, 4.
• The timing of apixaban cessation and resumption should be individualized based on the patient's specific needs and medical history 3.
• Close monitoring of the patient's anticoagulation status and bleeding risk is crucial when stopping apixaban prior to facet joint injections 4.