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)]
Use of drugs that induce the activity of CYP2C19 would be expected to result in increased drug levels of the active metabolite of clopidogrel and might potentiate the bleeding risk. As a precaution, avoid concomitant use of strong CYP2C19 inducers [see Drug Interactions (7.1)and Clinical Pharmacology (12. 3)]
Risk factors for bleeding include concomitant use of other drugs that increase the risk of bleeding (e.g., anticoagulants, antiplatelet agents, and chronic use of NSAIDs)
The management plan for anticoagulation and antiplatelet therapy in a patient with a recently placed coronary stent who is taking Plavix (clopidogrel) and Eliquis (apixaban) and needs to undergo a procedure that may increase the risk of bleeding is to discontinue apixaban at least 48 hours prior to the procedure and consider the risk of bleeding with concomitant use of clopidogrel and other drugs that increase the risk of bleeding. It is also recommended to avoid concomitant use of strong CYP2C19 inducers with clopidogrel. The decision to discontinue or modify antiplatelet and anticoagulant therapy should be made on a case-by-case basis, taking into account the individual patient's risk of bleeding and thrombotic events 1 2.
- Key considerations:
- Discontinue apixaban at least 48 hours prior to the procedure
- Avoid concomitant use of strong CYP2C19 inducers with clopidogrel
- Consider the risk of bleeding with concomitant use of clopidogrel and other drugs that increase the risk of bleeding
- Individualize the decision to discontinue or modify antiplatelet and anticoagulant therapy based on the patient's risk of bleeding and thrombotic events.
From the Research
The management plan for anticoagulation and antiplatelet therapy in a patient with a recently placed coronary stent who is taking Plavix (clopidogrel) and Eliquis (apixaban) and needs to undergo a procedure that may increase the risk of bleeding involves temporarily discontinuing these medications while balancing bleeding and thrombotic risks, with the most recent guidelines suggesting dual therapy with a single antiplatelet agent and an oral anticoagulant is effective and associated with less bleeding risk 3.
Key Considerations
- The timing of Plavix (clopidogrel) discontinuation critically depends on stent placement timing, with a recommended minimum of 5-7 days prior to the procedure, but this may need to be adjusted based on the type of stent and the time since placement.
- For patients with a high risk of thrombosis, aspirin can be continued for up to 1 month, and dual therapy with clopidogrel and an oral anticoagulant such as apixaban should be continued for 12 months 3.
- The decision to discontinue or continue antiplatelet and anticoagulation therapy should be based on the individual patient's risk of bleeding and thrombosis, as well as their overall clinical condition.
Procedure-Related Recommendations
- For most procedures, Eliquis (apixaban) should be stopped 48 hours before the procedure (72 hours if high bleeding risk or renal impairment).
- After the procedure, restart Eliquis within 24-48 hours once hemostasis is achieved, and resume clopidogrel with a loading dose of 300-600mg followed by 75mg daily.
- Consider bridging with cangrelor or a glycoprotein IIb/IIIa inhibitor for the clopidogrel pause in urgent procedures during the critical period after stent placement.
Ongoing Management
- Dual therapy with a single antiplatelet agent and an oral anticoagulant is the preferred regimen for patients with atrial fibrillation undergoing coronary artery stenting, with clopidogrel and apixaban being a commonly used combination 3.
- The duration of dual therapy should be individualized based on the patient's risk of bleeding and thrombosis, but should generally be continued for at least 12 months after stent placement.