Timing of Epidural Placement After Edoxaban (Savaysa) Administration
For patients on edoxaban (Savaysa), epidural placement should be delayed for at least 48 hours after the last dose in patients with normal renal function, and longer in those with renal impairment. 1
Discontinuation Timeline Based on Renal Function
| Renal Function | Minimum Time Between Last Edoxaban Dose and Epidural Placement |
|---|---|
| Normal (CrCl ≥80 mL/min) | ≥48 hours |
| Moderate impairment (CrCl 50-79 mL/min) | ≥48 hours |
| Severe impairment (CrCl 30-49 mL/min) | ≥48 hours |
| Very severe impairment (CrCl 15-29 mL/min) | ≥48 hours (some guidelines suggest ≥72 hours) |
Key Considerations for Neuraxial Procedures
- High bleeding risk procedure: Neuraxial anesthesia/puncture (including epidural placement) is classified as a very high hemorrhagic risk procedure 1
- Strong recommendation: The French Working Group on Perioperative Hemostasis (GIHP) strongly recommends against performing spinal or epidural anesthesia in patients with possible residual edoxaban concentration 1
- Special caution: Particular attention should be paid to elderly patients (>80 years) and those with renal impairment 1
- No bridging needed: Preoperative bridging with heparin is not recommended when following appropriate discontinuation protocols 1
Resumption of Edoxaban After Epidural Placement
- Wait at least 6 hours after epidural placement before resuming edoxaban if there is no ongoing bleeding 1
- For high bleeding risk procedures (including neuraxial anesthesia):
Epidural Catheter Management
- If an epidural catheter is in place, therapeutic anticoagulation must be administered with heparin to safely withdraw the catheter 1
- Do not resume edoxaban while an epidural catheter is in place
- Wait at least 6 hours after catheter removal before administering the first dose of edoxaban 1
Monitoring Recommendations
- No routine laboratory monitoring of anticoagulant effect is required before epidural placement if appropriate discontinuation times are followed 1
- If there is concern about residual anticoagulant effect, specific anti-Xa activity can be measured, though this is not routinely necessary 1
Important Caveats
- The EMIT-AF/VTE study showed low bleeding risk with edoxaban in periprocedural settings (0.4% major bleeding), but this was with appropriate discontinuation protocols 2
- Edoxaban cannot be effectively removed by hemodialysis, making careful timing of discontinuation critical 3
- Patients with higher risk factors (advanced age, low body weight, renal impairment) may have higher edoxaban concentrations and require longer discontinuation periods 4
Following these guidelines will help minimize the risk of spinal hematoma while maintaining appropriate anticoagulation for the patient's underlying condition.