When can Eliquis (apixaban) be resumed after chemoport placement?

Resumption of Apixaban (Eliquis) After Chemoport Placement

Apixaban (Eliquis) can be resumed 6 hours after chemoport placement if there is no ongoing bleeding or surgical contraindication, as this is considered a low hemorrhagic risk procedure.

Timing of Apixaban Interruption and Resumption

Pre-Procedure Management

• For patients on twice daily regimen (standard apixaban dosing):
  • Last dose should be taken on the morning of the day before the planned procedure 1
  • This provides approximately 24-48 hours of interruption before the procedure
  • No bridging with heparin or LMWH is recommended during this interruption 1

Post-Procedure Management

• For low hemorrhagic risk procedures like chemoport placement:
  • Resume apixaban at least 6 hours after the end of the procedure 1
  • For twice daily regimen (standard apixaban dosing): Resume the evening of the same day 1

Special Considerations

• If there is ongoing bleeding or surgical contraindication:
  • Delay resumption and consider venous thromboprophylaxis according to VTE risk 1
  • Follow the high-risk bleeding procedure protocol if bleeding concerns exist

Risk Assessment

Factors That May Delay Resumption

• Inadequate hemostasis at the surgical site
• Complications during the procedure
• High bleeding risk patient factors:
  • Renal impairment (CrCl <30 mL/min)
  • Concomitant use of medications that increase bleeding risk
  • History of bleeding disorders
  • Advanced age (>80 years)
  • Low body weight (≤60 kg)

Monitoring After Resumption

• Monitor for signs of bleeding at the insertion site
• Watch for hematoma formation
• No routine laboratory monitoring is required when resuming apixaban 2

FDA Guidance

According to the FDA label, apixaban should be restarted after surgical procedures "as soon as adequate hemostasis has been established" 3. For low bleeding risk procedures like chemoport placement:

• Discontinue at least 24 hours prior to the procedure
• Resume when adequate hemostasis is achieved (typically 6 hours post-procedure)

Common Pitfalls to Avoid

1. Unnecessary prolonged interruption: Extending the time off anticoagulation increases thrombotic risk without clinical benefit
2. Bridging with heparin products: Not recommended for DOACs and may increase bleeding risk 1, 2
3. Failure to assess hemostasis: Always ensure adequate hemostasis before resuming anticoagulation
4. Overlooking drug interactions: P-gp and strong CYP3A4 inhibitors may require dose adjustment when resuming 3
5. Doubling doses: If a dose is missed, take as soon as possible on the same day but do not double the dose 3

Algorithm for Decision Making

1. Confirm procedure is low bleeding risk (chemoport placement typically is)
2. Hold apixaban according to schedule (last dose morning of day before procedure)
3. Perform procedure
4. Assess for adequate hemostasis at 6 hours post-procedure
5. If hemostasis is adequate → resume apixaban that evening
6. If concerns about hemostasis → delay resumption and reassess in 24 hours

This approach balances the risk of thromboembolism against the risk of bleeding, prioritizing patient morbidity and mortality outcomes.