How long should Eliquis (apixaban) be held before a thoracentesis procedure?

Perioperative Management of Apixaban (Eliquis) for Thoracentesis

For patients on apixaban (Eliquis), discontinue the medication at least 48 hours prior to thoracentesis if the patient has normal renal function, and extend this to 72 hours if renal function is impaired (CrCl <30 mL/min). 1, 2

Risk Stratification for Thoracentesis

Thoracentesis is generally considered a moderate bleeding risk procedure according to the American College of Chest Physicians guidelines. The management of apixaban should be based on:

1. Renal function assessment:

   • Normal to mild impairment (CrCl ≥50 mL/min): Hold apixaban for 48 hours (skip 4 doses)
   • Moderate impairment (CrCl 30-50 mL/min): Hold apixaban for 72 hours (skip 6 doses)
   • Severe impairment (CrCl <30 mL/min): Hold apixaban for 96 hours (skip 8 doses)

2. Bleeding risk of procedure:

   • Thoracentesis is classified as a moderate bleeding risk procedure
   • The risk of bleeding complications from thoracentesis is generally low (<1%) 3

Evidence-Based Recommendations

The FDA label for apixaban specifically states that it should be discontinued at least 48 hours prior to elective procedures with moderate or high risk of clinically significant bleeding 2. This aligns with the 2022 American College of Chest Physicians guidelines which recommend:

• For moderate bleeding risk procedures: Hold apixaban for 2 days (48 hours) before the procedure if CrCl ≥30 mL/min 1
• For high bleeding risk procedures: Hold apixaban for 3 days (72 hours) before the procedure 1

Special Considerations

1. Patients with high thrombotic risk:

   • If the patient has a recent history of stroke, venous thromboembolism, or mechanical heart valve, the decision to interrupt anticoagulation should be carefully weighed against the risk of thrombosis
   • Consider consultation with hematology or cardiology for high-risk patients

2. Ultrasound guidance:

   • Always use ultrasound guidance for thoracentesis as it has been shown to decrease the risk of bleeding complications 3

3. No need for bridging:

   • The rapid offset and onset of action of apixaban eliminates the need for bridging with heparin or LMWH in the perioperative setting 1

Resumption of Apixaban

• Resume apixaban at least 24 hours after thoracentesis if adequate hemostasis has been achieved 1, 2
• For patients at higher thrombotic risk, consider resuming apixaban earlier (12-24 hours post-procedure) if hemostasis is adequate 4
• Use the full therapeutic dose when restarting, as apixaban has a rapid onset of action

Emerging Evidence

Recent studies suggest that thoracentesis may be safely performed without prior correction of coagulopathy in some cases 3, 5, but these findings have not yet been incorporated into major guidelines. Until more robust evidence is available, following the established guidelines from the American College of Chest Physicians is recommended to minimize the risk of bleeding complications.

Common Pitfalls to Avoid

1. Unnecessary laboratory testing: Standard coagulation tests (PT/INR, aPTT) are not reliable for measuring apixaban activity 4

2. Inappropriate bridging: Unlike warfarin, bridging anticoagulation with heparin is not recommended when stopping apixaban 1

3. Delayed resumption: Unnecessarily prolonged interruption of anticoagulation increases thrombotic risk

4. Failure to adjust for renal function: Patients with impaired renal function require longer periods of apixaban interruption before procedures 1, 4