What are the guidelines for administering a shoulder injection to a patient taking Eliquis (apixaban)?

Management of Shoulder Injection in Patients Taking Eliquis (Apixaban)

For patients on apixaban (Eliquis) requiring a shoulder injection, the medication should be temporarily discontinued according to the bleeding risk of the procedure, with the last dose taken the morning of the day before the planned injection for this low-risk procedure. 1

Classification of Bleeding Risk for Shoulder Injections

Shoulder injections are generally considered low hemorrhagic risk procedures. According to the French Working Group on Perioperative Hemostasis (GIHP) guidelines, procedures with low hemorrhagic risk can be performed with minimal interruption of direct oral anticoagulants (DOACs) like apixaban.

Management Protocol for Patients on Apixaban

Pre-procedure Management:

• For twice daily regimen (standard apixaban dosing):

  • Last dose should be taken on the morning of the day before the planned injection
  • This provides sufficient time for drug levels to decrease while minimizing thromboembolic risk

• For once daily regimen:

  • If taken in the morning: Last dose on the morning of the day before the procedure
  • If taken in the evening: Last dose two days before the procedure

Bridging Strategy:

• No preoperative bridging with heparin (UFH or LMWH) is recommended 1
• No need to measure apixaban concentration before the procedure

Post-procedure Management:

• Resume apixaban at least six hours after the injection if there are no bleeding complications:
  • For twice daily regimen: Resume the evening of the same day
  • For once daily morning regimen: Resume the next morning
  • For once daily evening regimen: Resume the evening of the procedure day

Special Considerations

Renal Function:

• For patients with impaired renal function (CrCl 30-50 mL/min), no additional adjustment to the interruption schedule is needed for apixaban, unlike dabigatran which would require longer interruption 1
• Ensure a recent creatinine level is available

Injection Technique Considerations:

• Use aseptic technique for the injection 2
• Avoid injecting corticosteroid solution directly into tendons 2
• For optimal safety and efficacy, inject into the overlying bursal space or tendon sheath 2
• Patient should be in a sitting position for the procedure 2

Common Pitfalls to Avoid

1. Unnecessary prolonged discontinuation: Stopping apixaban for too long increases thromboembolic risk
2. Bridging with heparin: Not recommended and may increase bleeding risk without benefit regarding thromboembolic risk 1
3. Repeated injections: Not advised for shoulder conditions 2
4. Failure to resume anticoagulation: Ensure timely resumption of apixaban to prevent thromboembolic events
5. Injecting directly into tendons: This can cause tendon damage and should be avoided 2

Follow-up Recommendations

• Monitor for any signs of bleeding or hematoma formation at the injection site
• If there is ongoing bleeding after the procedure, delay resumption of apixaban and consider venous thromboprophylaxis according to individual risk 1
• Assess renal function post-procedure if the patient's medical condition could affect kidney function, as this may require dose adjustment of apixaban 1

By following these guidelines, shoulder injections can be safely performed in patients taking apixaban with minimal risk of bleeding complications while maintaining protection against thromboembolic events.