From the Guidelines
For a patient on Eliquis (apixaban) and Plavix (clopidogrel) with a recent coronary stent undergoing transperineal prostate biopsy, the recommended approach is to continue Plavix without interruption while temporarily discontinuing Eliquis, holding it for 48 hours before the procedure and resuming it 48 hours after the procedure if hemostasis is adequate, as suggested by the most recent guidelines 1. The rationale behind this approach is to balance the competing risks of bleeding and thrombosis, as continuing antiplatelet therapy with Plavix protects against stent thrombosis, which can be catastrophic, while briefly interrupting the direct oral anticoagulant Eliquis reduces procedural bleeding risk. Some key points to consider in this management include:
- The transperineal approach for prostate biopsy is preferred over the transrectal approach in anticoagulated patients as it carries a lower bleeding risk, as noted in studies on anticoagulation and antiplatelet therapy in urological practice 1.
- Close monitoring for bleeding complications is essential post-procedure.
- The management should be coordinated between the urologist and cardiologist to individualize the approach based on the patient's specific thrombotic and bleeding risk factors.
- According to the guidelines, for patients on apixaban, the last dose should not be taken later than 48 hours before the procedure, and the drug can be resumed 48 hours after the procedure if hemostasis is adequate 1.
- Bridging anticoagulation is not recommended unless a longer period of interruption occurs, and the use of a radial approach may allow for a shorter duration of anticoagulant discontinuation 1.
From the Research
Anticoagulation Management for Transperineal Prostate Biopsy
The patient in question is on Eliquis (apixaban) and Plavix (clopidogrel) with a coronary stent placed a few months ago and is scheduled for a transperineal prostate biopsy. The recommended anticoagulation management for this patient can be informed by the following considerations:
- Bleeding Risk: The use of triple antithrombotic therapy, which includes an anticoagulant (such as apixaban) and two antiplatelet drugs (such as aspirin and clopidogrel), is associated with an increased risk of bleeding 2, 3.
- Current Guidelines: Recent guidelines suggest that dual therapy, consisting of an oral anticoagulant and a single antiplatelet agent, may be effective and associated with less bleeding risk than triple therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI) with stent placement 4.
- Individualized Approach: The approach to antithrombotic therapy should be individualized, balancing bleeding and ischemic risks, and is typically managed by the patient's cardiologist 5.
Key Considerations for Anticoagulation Management
- Discontinuation of Antiplatelet Therapy: Discontinuation of clopidogrel early after drug-eluting stent placement is a major predictor of stent thrombosis 6.
- Dual Therapy: Dual therapy with an oral anticoagulant (such as apixaban) and a single antiplatelet agent (such as clopidogrel) may be a suitable alternative to triple therapy, with a lower risk of bleeding 4.
- Bleeding Risk Assessment: Patients on triple therapy, including those with a coronary stent and on anticoagulation, should be assessed for their bleeding risk, and the antithrombotic regimen should be adjusted accordingly 2, 3.
Recommendations for Transperineal Prostate Biopsy
- Consultation with Cardiologist: The patient's cardiologist should be consulted to determine the best approach to anticoagulation management for the transperineal prostate biopsy.
- Assessment of Bleeding Risk: The patient's bleeding risk should be assessed, and the antithrombotic regimen should be adjusted to minimize this risk.
- Dual Therapy Consideration: Dual therapy with apixaban and clopidogrel may be considered as an alternative to triple therapy, depending on the patient's individual risk factors and the cardiologist's recommendation 4.