Can a patient taking Eliquis (apixaban) undergo HD (Hemodialysis) catheter replacement and do they need to discontinue Eliquis before the procedure?

HD Catheter Replacement While on Eliquis (Apixaban)

Patients on Eliquis (apixaban) should discontinue the medication at least 24-48 hours before HD catheter replacement, as this is considered a procedure with moderate bleeding risk, and should resume Eliquis at least 6 hours after the procedure once adequate hemostasis has been established.

Timing of Eliquis Discontinuation

The timing of Eliquis discontinuation depends on the bleeding risk of the procedure:

• HD catheter replacement: Considered a moderate bleeding risk procedure
  • Discontinue Eliquis 24-48 hours before the procedure 1
  • For patients with normal renal function (CrCl ≥50 mL/min): 48 hours 2
  • For patients with moderate renal impairment (CrCl 30-50 mL/min): 72 hours 2
  • For patients with severe renal impairment (CrCl <30 mL/min): Consult hematology 2

Risk Assessment Considerations

Several factors increase the risk of bleeding during invasive procedures like HD catheter replacement:

• Advanced age (≥75 years)
• History of bleeding
• Concurrent use of antiplatelet agents, NSAIDs, or SSRIs
• Active cancer
• Severe liver dysfunction
• Severe coagulopathy 2

Resuming Anticoagulation After HD Catheter Replacement

• Resume Eliquis at least 6 hours after the procedure once adequate hemostasis has been established 2, 1
• If immediate thromboprophylaxis is needed post-procedure, consider prophylactic dose heparin or LMWH starting 6 hours after the procedure until Eliquis can be safely resumed 2

Important Considerations

• Bridging anticoagulation during the 24-48 hours after stopping Eliquis and prior to the procedure is not generally required 1
• Standard coagulation tests are not reliable for monitoring Eliquis activity 2
• If concerned about residual anticoagulant effect, specific anti-Xa assays can be considered, though they are not routinely recommended 2
• Ultrasound guidance is strongly recommended for catheter placement to reduce the risk of complications 2

Special Populations

• For hemodialysis patients on Eliquis for atrial fibrillation, careful consideration of risks vs. benefits is needed as bleeding events are approximately 10-fold more frequent than stroke or systemic embolism in this population 3
• Exposure to Eliquis in hemodialysis patients is dependent on both drug dose and timing of intake relative to the hemodialysis procedure 4

Pitfalls to Avoid

• Do not double the dose of Eliquis when resuming after the procedure 1
• Do not rely on standard coagulation tests to determine residual Eliquis effect 2
• Avoid placing HD catheters while the patient is still on therapeutic Eliquis due to increased bleeding risk 2
• Remember that Eliquis has a relatively short half-life, which eliminates the need for heparin bridging in most perioperative settings 2

Following these guidelines will help minimize both bleeding complications during HD catheter replacement and thrombotic events during the perioperative period for patients on Eliquis.