How many days to discontinue apixaban (Apixaban) before undergoing a lumbar puncture?

From the Guidelines

Apixaban should be discontinued at least 48 hours (2 days) before a lumbar puncture in patients with normal renal function, and 72 hours (3 days) before the procedure in patients with impaired kidney function (creatinine clearance <30 mL/min). This recommendation is based on the pharmacokinetic properties of apixaban, with a half-life of approximately 12 hours, allowing 4-5 half-lives to elapse before the procedure, which reduces the drug concentration to minimal levels 1. The American College of Chest Physicians clinical practice guideline suggests that the interruption of direct oral anticoagulants (DOACs) before an elective surgery/procedure can follow a pharmacokinetic-based approach, whereby the pre-operative interruption interval corresponds to four to five elimination half-lives of each DOAC 1. Some key points to consider when discontinuing apixaban before a lumbar puncture include:

• The patient's renal function, as impaired kidney function may require a longer discontinuation period
• The patient's specific bleeding risk and thrombotic risk
• The type of procedure being performed, as lumbar puncture is considered a high-bleed-risk procedure
• Consultation with the physician performing the procedure and the prescriber of the anticoagulant to determine the optimal management strategy for each individual patient. It is also important to note that after the lumbar puncture, apixaban can usually be resumed 24 hours later if there were no complications, but this should be individualized based on the patient's specific situation 1.

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.

A lumbar puncture is considered an invasive procedure with a moderate risk of bleeding.

• The recommended duration to discontinue apixaban before undergoing a lumbar puncture is at least 48 hours 2.

From the Research

Apixaban Discontinuation Before Lumbar Puncture

• The decision to discontinue apixaban before a lumbar puncture depends on various factors, including the patient's individual risk of thrombosis and bleeding, as well as the specific procedure being performed 3, 4, 5.
• According to the available evidence, apixaban should be discontinued for at least 48 hours before a lumbar puncture to minimize the risk of bleeding 6.
• However, the optimal duration of apixaban discontinuation before a lumbar puncture is not well established, and the decision should be made on a case-by-case basis, taking into account the patient's individual risk factors and the specific procedure being performed 4, 5.
• It is also important to note that the risk of thromboembolic events should be weighed against the risk of bleeding when deciding whether to discontinue apixaban before a lumbar puncture 3, 5.
• In patients with a high risk of thrombosis, bridging therapy with low molecular weight heparin or unfractionated heparin may be considered during the period of apixaban discontinuation 5.

Key Considerations

• The patient's individual risk of thrombosis and bleeding should be assessed before discontinuing apixaban 3, 4, 5.
• The specific procedure being performed, including the type of lumbar puncture and the use of any additional medications, should be taken into account when deciding whether to discontinue apixaban 4, 5.
• The optimal duration of apixaban discontinuation before a lumbar puncture is not well established and should be determined on a case-by-case basis 4, 5, 6.