When should Eliquis (apixaban) be held before abdominal paracentesis?

Timing of Eliquis (Apixaban) Discontinuation Before Abdominal Paracentesis

Eliquis (apixaban) should be discontinued at least 48 hours before abdominal paracentesis, and 72 hours before the procedure in patients with moderate renal impairment (CrCl 30-50 mL/min). 1, 2

Risk Stratification for Paracentesis

Abdominal paracentesis is generally considered a high-risk procedure for bleeding complications when performed in patients on anticoagulation therapy. While the absolute risk of bleeding is relatively low (0.2-2.2% of procedures), the consequences can be serious 3.

Factors affecting bleeding risk:

• Procedure-related factors:

  • Large-volume paracentesis
  • Multiple needle passes
  • Inexperienced operator
  • Lack of ultrasound guidance 4

• Patient-related factors:

  • Severe liver dysfunction
  • Renal impairment
  • Severe coagulopathy (especially fibrinogen <0.70 g/L) 5
  • Concurrent use of other antiplatelet/anticoagulant medications

Specific Recommendations for Eliquis Management

Based on renal function:

• Normal renal function (CrCl ≥50 mL/min):

  • Discontinue Eliquis at least 48 hours before paracentesis 1, 2

• Moderate renal impairment (CrCl 30-50 mL/min):

  • Discontinue Eliquis at least 72 hours before paracentesis 1

• Severe renal impairment (CrCl <30 mL/min):

  • Consult hematology for individualized management 1

Special considerations:

• No bridging anticoagulation is typically required when stopping Eliquis 3, 1
• Recent case reports highlight potentially severe bleeding complications from paracentesis in patients with cirrhosis taking apixaban, suggesting extra caution may be warranted in this population 6

Resuming Eliquis After Paracentesis

• Resume Eliquis once adequate hemostasis has been achieved, typically 24-48 hours after the procedure 3, 1
• For patients at high thrombotic risk, consider resuming Eliquis earlier (same evening or next morning) if hemostasis is adequate 1

Contraindications to Paracentesis

Paracentesis should be avoided in patients with:

• Clinically evident hyperfibrinolysis
• Disseminated intravascular coagulation 3

Important Caveats

• Ultrasound guidance is strongly recommended to reduce the risk of complications and improve success rates 4
• Traditional coagulation parameters (INR, platelet count) are not reliable predictors of bleeding risk in cirrhotic patients 3, 7
• Prophylactic use of fresh frozen plasma or platelets before paracentesis is generally not recommended 3
• Patients with cirrhosis and concurrent apixaban use may be at higher bleeding risk than previously recognized 6
• In emergency situations where paracentesis cannot be delayed, consider measuring anti-Xa levels if available, or consider reversal agents if significant bleeding risk 8

Monitoring After Procedure

• Monitor for signs of bleeding for at least 24 hours after the procedure
• Be vigilant for delayed bleeding, which can occur up to 1 week after the procedure 3
• Signs of bleeding include abdominal pain, distension, hypotension, or decreasing hemoglobin

By following these guidelines, the risk of bleeding complications from paracentesis in patients on Eliquis can be minimized while still maintaining appropriate anticoagulation for thrombotic risk.