From the Guidelines
Eliquis (apixaban) should typically be held for 48 hours before a thoracentesis procedure, as recommended by the most recent and highest quality study 1. This approach is based on a pharmacokinetic-based strategy, where the pre-operative interruption interval corresponds to four to five elimination half-lives of the medication. Given apixaban's half-life of approximately 12 hours, withholding the medication for 48 hours before the procedure should result in minimal to no residual anticoagulant effect at the time of surgery. The following factors should be considered when determining the timing of Eliquis discontinuation and resumption:
- Renal function: since apixaban is partially cleared by the kidneys, patients with impaired renal function may require a longer duration of pre-operative interruption 1
- Age, weight, and concurrent medications: these factors may affect the patient's bleeding risk and the complexity of the procedure
- Thrombotic risk: for patients at very high thrombotic risk, a bridging strategy with shorter-acting anticoagulants might be considered in consultation with the patient's cardiologist or hematologist After the thoracentesis is completed and hemostasis is confirmed, Eliquis can usually be resumed 24-48 hours later, depending on the patient's individual bleeding risk and the complexity of the procedure. It is essential to discuss the specific timing of medication discontinuation and resumption with the proceduralist performing the thoracentesis, as individual practice patterns may vary. Key points to consider:
- The 48-hour pre-procedure window allows for adequate clearance of the medication
- Patient-specific factors may require adjustment of the timing of medication discontinuation and resumption
- A bridging strategy with shorter-acting anticoagulants may be considered for patients at very high thrombotic risk
- The proceduralist's individual practice patterns should be taken into account when determining the timing of medication discontinuation and resumption.
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 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.
Eliquis (apixaban) should be held for at least 48 hours before a thoracentesis, as it is considered an invasive procedure with a moderate or high risk of bleeding. 2
From the Research
Holding Eliquis Before Thoracentesis
- There are no specific guidelines on how long to hold Eliquis (apixaban) before a thoracentesis, as the provided studies do not directly address this topic.
- However, studies such as 3 suggest that the decision to perform thoracentesis in patients on anticoagulants, including direct oral anticoagulants like apixaban, should be based on individual patient risk factors and the bleeding risk associated with the procedure.
- The study 4 discusses the use of heparin bridging in patients on chronic oral anticoagulants, including direct oral anticoagulants, during temporary interruption for an elective procedure, but does not provide specific guidance on holding apixaban before thoracentesis.
- Other studies, such as 5, 6, and 7, focus on the safety and efficacy of apixaban in treating venous thromboembolism, but do not address the specific question of holding apixaban before thoracentesis.
Considerations for Holding Anticoagulants
- When considering holding anticoagulants before a procedure, it is essential to weigh the risk of bleeding against the risk of thromboembolism, as discussed in 4.
- The decision to hold anticoagulants should be individualized, taking into account the patient's renal function, bleeding risk, and other factors, as mentioned in 5 and 6.
- More research is needed to provide clear guidance on holding apixaban before thoracentesis, as noted in 3 and 6.