Do you bridge Eliquis (apixaban) in patients undergoing procedures?

From the Guidelines

Apixaban (Eliquis) typically does not require bridging for most procedures, as evidenced by the most recent and highest quality study 1. For low bleeding risk procedures, apixaban can be continued without interruption. For procedures with moderate to high bleeding risk, apixaban should be held for a specific duration before the procedure, which varies based on renal function and the type of procedure being performed, as outlined in the 2020 ACC expert consensus decision pathway 1. The decision to hold apixaban should be individualized based on the patient's thrombotic risk, bleeding risk of the procedure, and renal function. Some key considerations include:

• For transradial PCI, apixaban should be held for 24 hours if creatinine clearance is ≥30 ml/min, and for 36 hours if creatinine clearance is 15-29 ml/min 1.
• For transfemoral PCI, apixaban should be held for 48 hours if creatinine clearance is ≥30 ml/min, and for a longer duration if creatinine clearance is less than 30 ml/min 1.
• Bridging with heparin or low molecular weight heparin is generally unnecessary because apixaban has a predictable, short half-life of approximately 12 hours 1. After the procedure, apixaban can be restarted at the regular dose once adequate hemostasis is established, typically 24 hours after minor procedures and 48-72 hours after major procedures with high bleeding risk. It is essential to consider the patient's individual risk factors and the specific procedure being performed when making decisions about apixaban management, and to consult with a specialist if necessary, particularly for patients with very high thrombotic risk 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 [see Warnings and Precautions (5. 2)] . 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. Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required

No, you do not bridge Eliquis (apixaban) in patients undergoing procedures, as bridging anticoagulation is not generally required during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention 2.

From the Research

Perioperative Management of Eliquis (Apixaban)

• The management of Eliquis (apixaban) in patients undergoing procedures is crucial to balance the risk of bleeding and thromboembolism 3.
• A standardized approach to perioperative Eliquis management involves classifying the risk of procedure-related bleeding as minimal, low to moderate, or high risk 3.
• For patients undergoing minimal bleeding risk procedures, Eliquis may be continued, or if there is concern about excessive bleeding, Eliquis may be discontinued on the day of the procedure 3.
• Patients undergoing a low to moderate bleeding risk procedure should typically discontinue Eliquis 1 day before the operation and restart Eliquis 1 day after 3.
• Patients undergoing a high bleeding risk procedure should stop Eliquis 2 days prior to the operation and restart Eliquis 2 days after 3.

Bridging Therapy with Heparin

• Bridging therapy with heparin is not typically recommended for patients taking Eliquis who require temporary interruption for an elective invasive procedure or surgery 4, 5.
• The use of bridging therapy with heparin has been associated with an increased risk of bleeding, particularly in patients with a low risk of thromboembolism 5.
• However, bridging therapy with heparin may be considered in patients with a high risk of thromboembolism, such as those with mechanical heart valves or a history of recurrent venous thromboembolism 4, 6.

Laboratory Testing and Reversal Agents

• Laboratory testing to measure preoperative Eliquis levels may be useful to determine whether patients should receive a reversal agent prior to an emergent or urgent procedure 3.
• Reversal agents, such as prothrombin complex concentrates, idarucizumab, or andexanet-α, may be appropriate when Eliquis levels are elevated or not available 3.