What are the indications to hold Eliquis (apixaban) for a patient with Deep Vein Thrombosis (DVT)?

From the Guidelines

Eliquis (apixaban) should be held in patients with DVT in several specific situations, including major surgery or invasive procedures with high bleeding risk, active pathological bleeding, severe thrombocytopenia, spinal/epidural anesthesia or puncture, severe renal impairment, or hepatic disease associated with coagulopathy. When considering the management of Eliquis in patients with DVT, it is essential to weigh the risk of recurrent thrombosis against the risk of bleeding, as stated in the guidelines for antithrombotic therapy for VTE disease 1. The following situations require holding Eliquis:

• Major surgery or invasive procedures with high bleeding risk, typically 48 hours before the procedure (longer for patients with renal impairment)
• Active pathological bleeding
• Severe thrombocytopenia (platelet count <50,000/μL)
• Spinal/epidural anesthesia or puncture, at least 24-48 hours beforehand due to risk of spinal hematoma
• Severe renal impairment (CrCl <15 mL/min)
• Hepatic disease associated with coagulopathy It is crucial to consult with the prescribing physician before holding Eliquis, as abrupt discontinuation can increase thrombotic risk, and the anticoagulant effect diminishes approximately 24-48 hours after the last dose in patients with normal renal function 1. In patients with DVT, the choice of anticoagulant is critical, and Eliquis is recommended over VKA therapy for long-term anticoagulant therapy, as suggested by the Chest guidelines 1. However, the decision to hold Eliquis should be made on a case-by-case basis, considering the individual patient's risk factors and medical history. Key factors to consider when holding Eliquis include:
• The patient's renal function, as severe renal impairment may require dose adjustment or alternative anticoagulation
• The patient's bleeding risk, as active pathological bleeding or severe thrombocytopenia may necessitate discontinuation of Eliquis
• The patient's medical history, including any previous episodes of DVT or PE, and any concomitant medications that may interact with Eliquis.

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 indications to hold Eliquis (apixaban) for a patient with a DVT include:

• Elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding: hold apixaban at least 48 hours prior to the procedure.
• Elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled: hold apixaban at least 24 hours prior to the procedure 2.

From the Research

Indications to Hold Eliquis for a Patient with a DVT

• The decision to hold Eliquis (apixaban) for a patient with a Deep Vein Thrombosis (DVT) depends on various factors, including the risk of recurrence, risk of bleeding, and patient preference 3.
• According to a study published in 2014, VTE provoked by a reversible risk factor, or a first unprovoked isolated distal (calf) DVT, has a low risk of recurrence and is usually treated for 3 months 3.
• However, if the patient has a high risk of recurrence, such as those with active cancer or a second unprovoked VTE, indefinite anticoagulation may be considered 3.
• A study published in 2023 found that apixaban was favored over warfarin for treating VTE in severe renal failure, reducing VTE recurrence and bleeding risk 4.
• Another study published in 2024 found that apixaban significantly decreased the risk of major bleeding compared to low molecular weight heparin (LMWH) in patients with cancer-associated VTE 5.
• In terms of holding Eliquis, there is no specific guidance on when to hold the medication, but it is generally recommended to hold anticoagulants if there is a high risk of bleeding or if the patient is undergoing a procedure that may increase the risk of bleeding 3, 6.
• The decision to hold Eliquis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3, 6, 5, 4.

Special Considerations

• Patients with severe renal failure may require dose adjustments or closer monitoring when taking Eliquis 4.
• Patients with cancer-associated VTE may require closer monitoring and more frequent follow-up appointments to manage their condition 5.
• Patients undergoing procedures that may increase the risk of bleeding should be closely monitored and may require temporary discontinuation of Eliquis 3, 6.