How long should Eliquis (apixaban) be held before paracentesis?

Apixaban Discontinuation for Paracentesis

For patients on apixaban (Eliquis), discontinue the medication 48 hours before paracentesis if creatinine clearance is ≥30 mL/min, and 72 hours before the procedure if creatinine clearance is <30 mL/min. 1, 2

Timing of Apixaban Discontinuation Based on Renal Function

• Normal to mildly impaired renal function (CrCl ≥30 mL/min):

  • Last dose: 48 hours before paracentesis (skip 2 doses)
  • This allows for 4-5 half-lives of drug elimination, resulting in minimal residual anticoagulant effect 1, 3

• Moderate to severe renal impairment (CrCl 15-29 mL/min):

  • Last dose: 72 hours before paracentesis (skip 3 doses)
  • Extended withholding period needed due to increased drug exposure with renal impairment 2, 1

Risk Assessment Considerations

Paracentesis has traditionally been considered a low bleeding risk procedure, but recent evidence suggests caution is warranted in certain populations:

• Higher risk patients:

  • Patients with cirrhosis 4
  • Patients with moderate to severe renal impairment 4
  • Patients on concomitant antiplatelet therapy

• Important clinical caveat: Despite paracentesis being classified as a "low bleeding risk" procedure in some guidelines, case reports have documented major bleeding complications in patients with cirrhosis and renal impairment taking apixaban 4. This warrants a more cautious approach in these specific populations.

Resumption of Apixaban After Paracentesis

• Resume apixaban 24 hours after the procedure if adequate hemostasis has been achieved 3
• For patients at high thrombotic risk (e.g., recent VTE, mechanical heart valve, or CHA₂DS₂-VASc score ≥4):
  • Consider resuming earlier (6-12 hours post-procedure) if hemostasis is adequate 2
  • Start with a reduced dose for the first day if concerned about bleeding risk 2

Laboratory Testing

• Standard coagulation tests (PT/INR, aPTT) are not reliable for measuring apixaban activity 1
• If available and urgent procedure is needed, consider specific anti-Xa assays calibrated for apixaban 1
• In the ADIOS study, apixaban levels ≤30 ng/mL were achieved in 94% of patients after discontinuation for ≥48 hours, confirming the safety of this approach 5

No Need for Bridging

• Unlike warfarin, bridging anticoagulation with heparin or LMWH is not recommended when stopping apixaban 3, 2
• The rapid offset and onset of action of apixaban eliminates the need for bridging therapy 1

Special Considerations

• Patients with high thrombotic risk: Balance bleeding vs. thrombotic risk; consider consulting hematology
• Emergency procedures: If paracentesis cannot be delayed, proceed with caution and monitor closely for bleeding
• Documentation: Clearly document the timing of last dose and planned resumption in the medical record

This approach aligns with the European Heart Rhythm Association and American College of Chest Physicians guidelines, which recommend a standardized perioperative DOAC management strategy based on procedure bleeding risk and renal function 2, 1.