What are the American Society of Regional Anesthesia (ASRA) guidelines for managing apixaban (eliquis) in patients undergoing regional anesthesia?

ASRA Guidelines for Managing Apixaban in Patients Undergoing Regional Anesthesia

According to the Association of Anaesthetists of Great Britain & Ireland guidelines, apixaban prophylaxis should be discontinued 24-48 hours before neuraxial procedures, with neuraxial catheters not recommended while on apixaban, and resumption of apixaban should occur at least 6 hours after catheter removal. 1

Preoperative Management of Apixaban

Timing of Discontinuation

• For neuraxial procedures (spinal/epidural anesthesia):

  • Discontinue apixaban 24-48 hours before the procedure 1
  • Longer discontinuation periods may be needed for patients with renal impairment:
    • Normal renal function (CrCl ≥50 mL/min): 48 hours for high bleeding risk procedures 2
    • Moderate renal impairment (CrCl 30-50 mL/min): 72 hours 2
    • Severe renal impairment (CrCl <30 mL/min): Consult hematology 2

• For peripheral nerve blocks:

  • Risk stratification is important:
    • High-risk blocks (paravertebral, deep plexus blocks): Follow same guidelines as neuraxial procedures 1
    • Low-risk superficial blocks: Less stringent timing may be acceptable

Laboratory Monitoring

• Standard coagulation tests (PT, INR, aPTT) are not reliable for monitoring apixaban activity
• If concerned about residual anticoagulant effect, specific anti-Xa assays can be considered 2
• Research shows that apixaban discontinuation for at least 48 hours before procedures results in clinically insignificant anticoagulation levels (≤30 ng/mL in 94% of patients) 3

Intraoperative Considerations

Neuraxial Procedures

• Neuraxial catheters are not recommended while on apixaban 1
• Traumatic needle/catheter placement increases bleeding risk and may require longer waiting periods before resuming apixaban
• Ultrasound guidance is strongly recommended to reduce vascular puncture risk 2

Peripheral Nerve Blocks

• Risk of bleeding complications varies by block location:
  • Deep blocks (lumbar plexus, paravertebral): Higher risk
  • Superficial blocks: Lower risk
• Catheter techniques may carry higher risk than single-shot blocks 1

Postoperative Management

Timing of Resumption

• Wait at least 6 hours after catheter removal before resuming apixaban 1
• For high bleeding risk procedures, resume apixaban 48-72 hours postoperatively 1
• For low bleeding risk procedures, resume apixaban 24 hours postoperatively 1

Dosing Recommendations

• Consider reduced dosing when initially resuming apixaban after high bleeding risk procedures:
  • For high thrombotic risk patients: Consider apixaban 2.5 mg twice daily initially 1
  • Resume full therapeutic dosing after adequate hemostasis is established

Special Considerations

Bridging Anticoagulation

• Unlike warfarin, bridging with heparin or LMWH is generally not necessary with apixaban due to its rapid onset of action 2
• If immediate postoperative thromboprophylaxis is needed before apixaban can be safely resumed, consider prophylactic dose heparin or LMWH starting 6 hours after the procedure 2

Emergency Procedures

• For urgent procedures where apixaban cannot be discontinued in advance:
  • Consider measuring anti-Xa activity if available
  • Specific reversal agents may be needed in emergent situations 4

Common Pitfalls and Caveats

• Do not use neuraxial catheters while on apixaban - this is explicitly not recommended in guidelines 1
• Avoid assuming standard coagulation tests accurately reflect apixaban activity
• Remember that catheter removal carries similar bleeding risks as insertion - follow the same timing guidelines
• The risk at the time of catheter removal is not negligible and requires the same precautions as insertion 1
• Recent research shows that with proper discontinuation protocols (≥48 hours), apixaban levels are typically below clinically significant thresholds before procedures 3, 5

By following these guidelines, clinicians can minimize both bleeding and thrombotic risks when managing patients on apixaban who require regional anesthesia.