How to manage anticoagulation with Plavix (clopidogrel) and Eliquis (apixaban) for a patient undergoing a transperineal prostate biopsy?

From the Guidelines

For a patient on both Plavix (clopidogrel) and Eliquis (apixaban) undergoing a transperineal prostate biopsy, I recommend temporarily discontinuing Eliquis for 48 hours before the procedure while continuing Plavix without interruption. This approach is based on the understanding that transperineal prostate biopsies have a lower risk of bleeding compared to transrectal biopsies, and the risk of bleeding with continued antiplatelet therapy like Plavix is manageable 1. The decision to continue Plavix is also influenced by the need to avoid increased cardiovascular risk, particularly in patients with recent coronary stents.

Key Considerations:

• The temporary discontinuation of Eliquis is reasonable due to its short half-life, allowing for rapid clearance and restoration of anticoagulation.
• For patients at very high thrombotic risk, such as those with recent venous thromboembolism or atrial fibrillation with a recent stroke, bridging with low-molecular-weight heparin during the Eliquis interruption should be considered.
• Prophylactic antibiotics, typically a fluoroquinolone or augmented aminopenicillin, should be administered before the procedure to minimize the risk of infection.
• Post-procedure monitoring for bleeding complications, such as hematuria, rectal bleeding, or perineal hematoma, is crucial for 24-48 hours.

Management Strategy:

The management of anticoagulation in patients undergoing transperineal prostate biopsy should be individualized, taking into account the patient's specific thrombotic risk, bleeding risk, and in consultation with the patient's cardiologist or prescribing physician. This personalized approach ensures that the risks of both thrombotic and bleeding complications are minimized, prioritizing the patient's morbidity, mortality, and quality of life. Given the information from 1, it's clear that the approach to managing anticoagulation and antiplatelet therapy must be tailored to the specific procedure and the patient's risk factors, emphasizing the importance of a multidisciplinary decision plan.

From the FDA Drug Label

2.3 Temporary Interruption for Surgery and Other Interventions 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 5.2 General Risk of Bleeding P2Y12 inhibitors (thienopyridines), including clopidogrel, increase the risk of bleeding.

For a patient undergoing a transperineal prostate biopsy while on Plavix (clopidogrel) and Eliquis (apixaban), the management of anticoagulation should be as follows:

• Discontinue Eliquis (apixaban) at least 48 hours prior to the procedure to minimize the risk of bleeding, as it is a procedure with a moderate to high risk of clinically significant bleeding.
• Discontinue Plavix (clopidogrel) for 5 days prior to the procedure if possible, to reduce the risk of bleeding.
• After the procedure, restart both Eliquis (apixaban) and Plavix (clopidogrel) as soon as possible, once adequate hemostasis has been established, to minimize the risk of thrombotic events. It is crucial to weigh the risks of bleeding against the risks of thrombotic events when making decisions about anticoagulation management in this context. Consultation with a specialist may be necessary to determine the best approach for individual patients. 2 2 3

From the Research

Management of Anticoagulation for Transperineal Prostate Biopsy

• The management of anticoagulation with Plavix (clopidogrel) and Eliquis (apixaban) for a patient undergoing a transperineal prostate biopsy is a critical consideration to minimize the risk of bleeding complications.
• A study published in 2017 4 found that transperineal ultrasound-guided prostate biopsy is safe even when patients are on combination antiplatelet and/or anticoagulation therapy, suggesting that it may not be necessary to discontinue anticoagulant and/or antiplatelet agents when transperineal prostate biopsy is contemplated.
• The study compared complications in patients taking single antiplatelet, single anticoagulant, and dual antiplatelet and/or anticoagulant agents and found that hematuria was more frequent in patients taking a single anticoagulant or two anti-thromboembolic agents compared with those taking a single antiplatelet agent.

Bleeding Complications and Anticoagulation

• Another study published in 2012 5 analyzed bleeding complications related to increasing sample number regimes in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy and found that there is an increased risk of bleeding complications with increased sampling numbers, but these are minor.
• The study also found that there is no significant association between minor bleeding complications and warfarin use, but there is a significant association between minor bleeding complications and low-dose aspirin use.
• However, it is essential to note that the study was focused on transrectal ultrasound-guided prostate biopsy, and the results may not be directly applicable to transperineal prostate biopsy.

Transperineal Prostate Biopsy Technique

• A step-by-step guide for performing in-office transperineal prostate biopsy using biplanar ultrasound guidance was published in 2019 6, which highlights the feasibility and safety of the procedure in an office setting.
• The guide emphasizes the importance of proper alignment of the biopsy needle with the ultrasound probe and the use of a disposable needle guide to minimize the number of individual needle sticks to the perineal skin.

Benefits of Transperineal Prostate Biopsy

• Transperineal prostate biopsy has been shown to offer several benefits, including improved sampling of the anterior prostate, reduced risk of infectious complications, and reduced risk of bleeding complications compared to transrectal prostate biopsy 7, 8.
• A study published in 2021 8 found that transperineal prostate biopsy was associated with an increased likelihood of upgrading to clinically significant prostate cancer among men on active surveillance for very low or low-risk prostate cancer.