Should Eliquis (apixaban) be stopped prior to lateral stent placement and prostate biopsy?

Management of Apixaban (Eliquis) Before Lateral Stent Placement and Prostate Biopsy

Apixaban (Eliquis) should be discontinued at least 48 hours prior to lateral stent placement and prostate biopsy due to the moderate bleeding risk associated with these urological procedures. 1, 2

Discontinuation Protocol for Apixaban

• For elective urological procedures with moderate bleeding risk (including prostate biopsy):
  • Stop apixaban 48 hours before the procedure 1, 2
  • No bridging anticoagulation is generally required during this 48-hour window 2
  • The timing allows for adequate clearance of the medication, with studies showing that >94% of patients achieve clinically insignificant apixaban levels (≤30 ng/mL) after at least 48 hours of discontinuation 3

Procedure-Specific Considerations

For Prostate Biopsy:

• Prostate biopsy carries a moderate bleeding risk that warrants temporary discontinuation of direct oral anticoagulants (DOACs) like apixaban
• While prostate biopsy can be performed safely in patients on low-dose aspirin with only a slightly higher risk of minor bleeding (approximately one-third higher than controls), full anticoagulation with apixaban presents a substantially higher bleeding risk 1

For Lateral Stent Placement:

• Urological procedures involving stent placement typically require discontinuation of anticoagulation due to the risk of bleeding
• Unlike ureteroscopy, which can be performed with continuing oral anticoagulation, stent placement procedures generally require temporary cessation of anticoagulants 1

Resumption of Anticoagulation

• Resume apixaban as soon as adequate hemostasis has been established, typically 24-48 hours after the procedure 2
• For procedures with low bleeding risk: Resume at approximately 24 hours post-procedure
• For procedures with higher bleeding risk: Resume at 48-72 hours post-procedure
• The specific timing should be determined based on the observed hemostasis and any post-procedural bleeding

Special Considerations

• For patients at high risk of thromboembolism:

  • Consider cardiology consultation before the procedure to assess the need for bridging therapy 1
  • High-risk patients include those with recent stroke, mechanical heart valves, or recent venous thromboembolism

• For emergency procedures:

  • If the procedure cannot be delayed for 48 hours, consultation with hematology/cardiology is strongly advised 1
  • Prothrombin Complex Concentrate (PCC) may be considered for urgent reversal if surgery cannot be delayed 4

Monitoring Recommendations

• Monitor the surgical site for bleeding every 30 minutes initially after the procedure
• Check vital signs regularly during the immediate post-procedure period
• Be vigilant for signs of delayed bleeding, particularly when anticoagulation is resumed

Pitfalls to Avoid

1. Inadequate discontinuation time: Failing to stop apixaban at least 48 hours before the procedure increases bleeding risk
2. Premature resumption: Restarting anticoagulation before adequate hemostasis is achieved can lead to significant bleeding complications
3. Overlooking high thrombotic risk: Some patients may require bridging therapy or shorter discontinuation periods despite bleeding concerns
4. Failure to consider renal function: Patients with impaired renal function may require longer discontinuation periods due to delayed clearance of apixaban

By following these evidence-based recommendations, the risk of both bleeding complications and thromboembolic events can be appropriately balanced for patients undergoing lateral stent placement and prostate biopsy while on apixaban therapy.