Should I hold Eliquis (apixaban) before a right lower extremity angiogram?

Management of Apixaban for Right Lower Extremity Angiogram

Apixaban (Eliquis) should be discontinued at least 24 hours prior to a right lower extremity angiogram, as this procedure is considered a low bleeding risk intervention. 1

Rationale for Timing of Discontinuation

The FDA label for apixaban clearly states that for elective procedures or invasive interventions with a low risk of bleeding (where bleeding would be non-critical in location and easily controlled), apixaban should be discontinued at least 24 hours prior to the procedure 1. A lower extremity angiogram falls into this category of low bleeding risk procedures.

Procedure-Specific Considerations

When managing anticoagulation for angiographic procedures:

• Bleeding risk classification: Lower extremity angiogram is considered a low bleeding risk procedure where bleeding is typically non-critical and easily controlled
• No bridging needed: Bridging anticoagulation during the 24-hour window after stopping apixaban and prior to the procedure is not generally required 1
• Renal function: No adjustment to the discontinuation timeline is needed based on renal function for apixaban (unlike dabigatran which would require longer discontinuation with impaired renal function) 2

Resumption Protocol

After the angiogram, apixaban should be restarted as follows:

• Resume apixaban only after adequate hemostasis has been established 1
• For low bleeding risk procedures like angiogram, apixaban can typically be resumed 6 hours after the procedure if there is no ongoing bleeding or surgical contraindication 2
• If twice-daily dosing regimen: Resume the evening of the same day as the procedure 2
• If once-daily evening dosing: Resume the evening of the procedure day 2
• If once-daily morning dosing: Resume the next morning 2

Important Considerations and Potential Pitfalls

1. Patient-specific thrombotic risk:

   • If the patient has very high thrombotic risk (recent VTE within 3 months, mechanical heart valve), discuss with the proceduralist about possibly shortening the discontinuation period

2. Procedural complications:

   • If there are any complications during the procedure that increase bleeding risk, delay resumption of apixaban accordingly

3. Common errors to avoid:

   • Discontinuing apixaban too early (>24 hours) unnecessarily increases thrombotic risk
   • Failing to resume anticoagulation promptly after the procedure increases thrombotic risk
   • Unnecessary bridging with heparin products may increase bleeding risk without benefit 2

By following this protocol, you can minimize both bleeding risk during the procedure and thrombotic risk from extended anticoagulant interruption.