How long should a patient be off Eliquis (apixaban) before a transforminal epidural injection?

Timing of Apixaban (Eliquis) Discontinuation Before Transforaminal Epidural Injection

Patients on apixaban (Eliquis) should discontinue the medication at least 3-5 days before undergoing a transforaminal epidural injection, depending on their renal function.

Discontinuation Timeline Based on Renal Function

For patients undergoing neuraxial procedures such as transforaminal epidural injections, which are classified as high bleeding risk procedures:

• Normal to mild renal impairment (CrCl ≥50 mL/min):

  • Stop apixaban 3 days before procedure (skip 4-6 doses)
  • Last dose should be taken 72 hours before the procedure 1

• Moderate renal impairment (CrCl 30-50 mL/min):

  • Stop apixaban 4 days before procedure (skip 6-8 doses)
  • Last dose should be taken 96 hours before the procedure 1

• Severe renal impairment (CrCl 15-29 mL/min):

  • Stop apixaban 5 days before procedure 2
  • Consider monitoring with anti-Xa levels if available

Rationale for Extended Discontinuation

Neuraxial procedures including epidural injections are classified as high bleeding risk procedures 2. The American College of Chest Physicians and other guidelines specifically categorize epidural injections as high-bleeding-risk procedures that require complete cessation of anticoagulant effect 2.

The extended discontinuation period (3-5 days) for neuraxial procedures is necessary because:

1. The consequences of epidural hematoma can be catastrophic, potentially resulting in permanent paralysis 2
2. Apixaban has a half-life of approximately 12 hours 3
3. Complete elimination of anticoagulant effect requires 4-5 half-lives (48-60 hours) 1
4. An additional safety margin is added for neuraxial procedures due to their high-risk nature

No Bridging Anticoagulation Required

Unlike vitamin K antagonists (e.g., warfarin), apixaban does not require bridging with heparin or low-molecular-weight heparin during the perioperative period 2, 1. The rapid offset and onset of action of direct oral anticoagulants like apixaban obviate the need for bridging therapy.

Resumption After Procedure

Apixaban can be resumed when adequate hemostasis is established:

• Typically at least 6 hours after the end of the procedure 1
• For epidural procedures, consider waiting 24 hours before resuming full anticoagulation 2
• If there is concern about bleeding, consider starting with prophylactic doses of heparin first, then transitioning to apixaban 1

Important Considerations and Caveats

• The discontinuation timeline should be discussed with both the proceduralist and the provider who prescribed apixaban
• Patients with very high thrombotic risk may require special consideration and individualized approaches
• The FDA label for apixaban recommends discontinuation at least 48 hours prior to procedures with moderate or high risk of bleeding 4
• Recent research suggests that apixaban discontinuation for at least 48 hours results in clinically insignificant anticoagulation levels in most patients 5, but guidelines recommend longer periods for neuraxial procedures specifically

Following these guidelines will help minimize the risk of epidural hematoma while balancing the need to resume anticoagulation to prevent thrombotic events.