What is the recommended duration to hold Eliquis (apixaban) for a procedure in a patient with unprovoked pulmonary embolism (PE)?

From the Guidelines

For a patient with unprovoked pulmonary embolism (PE) being treated with Eliquis (apixaban), it is recommended to hold the medication for at least 48 hours before a procedure to minimize bleeding risk, as suggested by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. When considering the management of anticoagulation in patients undergoing procedures, the timing of interruption and resumption of apixaban should be guided by the pharmacological properties of the drug and the individual patient's risk factors.

• The half-life of apixaban is approximately 12 hours, which informs the decision to hold the medication for a certain period before a procedure.
• For patients with normal renal function, holding apixaban for 1 day (2 doses) before an elective procedure is generally considered sufficient, but for procedures that require complete hemostasis, such as major surgery, discontinuation for ≥48 hours is recommended 1.
• The decision to hold apixaban for 48 hours is also influenced by the lack of approved reversal agents for apixaban, which complicates management if bleeding occurs during or after the procedure.
• After the procedure, apixaban can usually be resumed 24-48 hours later, depending on the bleeding risk associated with the procedure and the achievement of adequate hemostasis.
• It is crucial to individualize the timing of apixaban interruption and resumption based on patient-specific factors, including renal function, age, and history of bleeding, and to consult with both the prescribing physician and the proceduralist before making any changes to the anticoagulation regimen.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

The recommended duration to hold Eliquis (apixaban) for a procedure is at least 48 hours for procedures with a moderate or high risk of bleeding and at least 24 hours for procedures with a low risk of bleeding 2.

From the Research

Recommended Duration to Hold Eliquis (Apixaban) for a Procedure

There are no specific studies provided that directly address the recommended duration to hold Eliquis (apixaban) for a procedure in a patient with unprovoked pulmonary embolism (PE). However, the following information can be gathered from the available studies:

• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 3.
• All patients with PE require therapeutic anticoagulation for at least three months 3.
• The current 2019 guidelines of the European Society of Cardiology (ESC) recommend that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant (NOAC) in preference to a vitamin K antagonist (VKA) 3.
• In patients with active cancer, Apixaban, Edoxaban, and Rivaroxaban are effective alternatives to treatment with LMWH 3.

Key Points to Consider

• The risk for recurrent PE after discontinuation of treatment is related to the features of the index PE event 3.
• Patients with a strong transient risk factor have a low risk of recurrence, and anticoagulation can be discontinued after three months 3.
• Patients with strong persistent risk factors (such as active cancer) have a high risk of recurrence and should receive anticoagulant treatment of indefinite duration 3.

Available Treatment Options

• Unfractionated heparin (UFH) is the drug of choice for prophylaxis and short-term treatment of pulmonary embolism 4.
• Low molecular weight heparins (LMWH) and fondaparinux are preferred over UFH in the initial anticoagulation of PE since they are associated with a lower risk of bleeding 3, 5.
• Oral anticoagulants are used for prophylaxis in high-risk patients and in long-term treatment of pulmonary embolism 4.