How long should Eliquis (apixaban) be held before an L4-L5 epidural steroid injection (ESI) in a patient with Factor V Leiden and a history of recent pulmonary embolism (PE)?

Apixaban (Eliquis) Discontinuation Before L4-L5 Epidural Steroid Injection in a Patient with Factor V Leiden and Recent PE

Apixaban should be discontinued for at least 3 days prior to an L4-L5 epidural steroid injection in a patient with Factor V Leiden and recent pulmonary embolism. 1

Rationale for Timing of Discontinuation

The timing of apixaban discontinuation before neuraxial procedures is critical due to the high bleeding risk associated with epidural procedures and the potentially catastrophic consequences of epidural hematoma.

• Standard recommendation: Apixaban should be held for at least 3 days before neuraxial procedures (with day 0 being the day of the procedure) when creatinine clearance is >30 mL/min 1
• Pharmacokinetics: Apixaban has a half-life of 9-14 hours and duration of action of 24 hours 1
• FDA guidance: The drug label indicates apixaban should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of significant bleeding 2

Risk Assessment and Considerations

Thromboembolic Risk

This patient has multiple risk factors placing them at high risk for recurrent thromboembolism:

• Recent PE (within 3 months is considered high risk) 1
• Factor V Leiden mutation (genetic thrombophilia) 1, 3

According to risk stratification guidelines, this patient would be classified as high risk for thromboembolism due to recent VTE (<3 months) 1.

Procedural Bleeding Risk

• Epidural steroid injections are classified as high hemorrhagic risk procedures
• Neuraxial anesthesia/puncture specifically requires a longer interruption time of direct oral anticoagulants (DOACs) 1
• The French Working Group on Perioperative Hemostasis (GIHP) strongly recommends not performing spinal or epidural procedures in patients with possible DOAC concentration due to insufficient discontinuation time 1

Management Algorithm

1. Pre-procedure (3 days before ESI):

   • Discontinue apixaban 3 days before the procedure (72 hours prior)
   • Ensure recent creatinine clearance is available and >30 mL/min

2. Bridging considerations:

   • Bridging with heparin is generally not required for most patients on DOACs 1
   • However, given this patient's high thrombotic risk (recent PE and Factor V Leiden):
     • Consider bridging with therapeutic LMWH if the PE occurred within the past month
     • Start LMWH 24 hours after last apixaban dose
     • Stop LMWH 24 hours before procedure

3. Post-procedure:

   • Resume apixaban once adequate hemostasis has been established, typically 24-48 hours after the procedure
   • If venous thromboprophylaxis is indicated during the immediate post-procedure period, consider prophylactic dose heparin starting at least 6 hours after the procedure 1

Important Caveats

• Laboratory monitoring: No routine laboratory monitoring is required for apixaban, but if there is concern about residual anticoagulant effect, an anti-Xa assay (with drug-specific calibrators) can be considered 1

• Renal function: Ensure recent renal function tests are available, as impaired renal function may require longer discontinuation periods

• Communication: Ensure clear communication between the interventional pain physician, primary physician, and any anticoagulation service involved in the patient's care

• Patient education: Instruct the patient about the exact timing of medication discontinuation and signs of thromboembolism to watch for during the period off anticoagulation

• Post-procedure vigilance: Monitor for signs of both bleeding and thromboembolism after the procedure

Following these guidelines will help minimize both the risk of procedural bleeding and the risk of thromboembolism in this high-risk patient.