When should Eliquis (apixaban) be stopped prior to a Transrectal Ultrasound (TRUS) guided prostate biopsy?

Apixaban Discontinuation Before TRUS-Guided Prostate Biopsy

Apixaban (Eliquis) should be discontinued 3 days before TRUS-guided prostate biopsy in patients with normal renal function, and 5 days before the procedure in patients with moderate renal impairment (CrCl 30-50 mL/min). 1

Discontinuation Timeline Based on Renal Function

The timing of apixaban discontinuation depends on the patient's renal function:

• Normal to mild renal impairment (CrCl ≥50 mL/min): Stop apixaban 3 days before the procedure 1
• Moderate renal impairment (CrCl 30-50 mL/min): Stop apixaban 5 days before the procedure 1
• Severe renal impairment (CrCl 15-29 mL/min): Stop apixaban 5 days before the procedure 1

This recommendation aligns with the European Society of Gastrointestinal Endoscopy (ESGE) guidelines which recommend that the last dose of DOACs be taken 3 days before high-risk endoscopic procedures 2. For patients with moderate renal impairment on dabigatran, the recommendation extends to 5 days, which can be applied to apixaban in similar circumstances 2.

Bridging Anticoagulation

• No bridging anticoagulation is recommended when interrupting direct oral anticoagulants like apixaban 1
• Bridging with heparin may increase bleeding risk without providing additional thromboembolic protection 1
• The FDA label for apixaban also states that "bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required" 3

Resumption of Apixaban

After the TRUS-guided prostate biopsy:

• Low bleeding risk: Resume apixaban 24 hours after the procedure 1
• High bleeding risk: Resume apixaban 48-72 hours after the procedure when adequate hemostasis is established 1

The FDA label recommends restarting apixaban "as soon as adequate hemostasis has been established" 3.

Risk Assessment for Prostate Biopsy

TRUS-guided prostate biopsy is considered a procedure with potential bleeding complications:

• The American Urological Association considers prostate biopsy to have a risk of bleeding, though it can be safely performed in patients on low-dose aspirin 2
• Bleeding complications include hematuria, rectal bleeding, and hematospermia 4

Special Considerations

1. High Thrombotic Risk Patients:

   • For patients with very high thrombotic risk (e.g., recent stroke, mechanical heart valves), consider individualized approaches with hematology consultation 1
   • Patients with cardiac stents require special consideration - surgery should be deferred for at least 6 weeks after bare-metal stent placement and 6 months after drug-eluting stent placement 1

2. Common Pitfalls to Avoid:

   • Insufficient discontinuation time
   • Premature resumption of anticoagulation
   • Failure to adjust for renal function
   • Inadequate communication between healthcare providers 1

Bleeding Risk with Anticoagulants During Prostate Biopsy

While some older studies suggest that continuing anticoagulation during TRUS biopsy may be safe 5, 6, more recent evidence and guidelines recommend temporary discontinuation of DOACs like apixaban due to the risk of bleeding complications 1, 7.

A study on heparin bridging therapy for TRUS biopsy showed significantly higher rates of complications in the bridging group compared to controls (35% vs 8.3%), particularly bleeding-related complications (27% vs 4.4%) 7, supporting the recommendation against routine bridging.

Following these evidence-based guidelines for apixaban discontinuation before TRUS-guided prostate biopsy will help minimize bleeding complications while managing thrombotic risk.