How long should Eliquis (apixaban) be held prior to thoracentesis?

Holding Eliquis (Apixaban) Prior to Thoracentesis

For patients taking Eliquis (apixaban), discontinue the medication at least 48 hours prior to thoracentesis as it is considered a procedure with moderate to high bleeding risk. 1

Bleeding Risk Classification of Thoracentesis

• Thoracentesis is generally classified as a moderate to high bleeding risk procedure, particularly when compared to other invasive procedures 2
• Although bleeding complications are relatively rare (occurring in less than 1% of cases), the potential consequences of bleeding in the pleural space can be significant 3
• The procedure involves penetration of vascular tissue and creation of a potential space where bleeding can accumulate 4

Specific Recommendations for Apixaban Discontinuation

Based on FDA Label and Guidelines:

• Apixaban (Eliquis) should be discontinued at least 48 hours prior to thoracentesis according to the FDA drug label 1
• For patients with normal renal function, this corresponds to approximately 4 half-lives of the drug (apixaban half-life is approximately 12 hours) 5
• No bridging anticoagulation is required during this interruption period due to the rapid offset and onset of action of direct oral anticoagulants (DOACs) 2

Considerations for Special Populations:

• For patients with renal impairment, the standard 48-hour discontinuation period is generally still appropriate as apixaban has only 27% renal clearance 5
• For patients at very high thrombotic risk, the 48-hour window still applies, as the bleeding risk of thoracentesis outweighs the short-term thrombotic risk 2

Resumption of Apixaban After Thoracentesis

• Resume apixaban at least 24 hours after thoracentesis if adequate hemostasis has been achieved 2, 1
• For patients with higher bleeding risk or if there were any procedural complications, consider delaying resumption to 48-72 hours post-procedure 2
• When restarting, use the regular prescribed dose without a loading dose 1

Emerging Evidence

• Some recent small studies suggest that thoracentesis may be safe in patients on anticoagulants, including NOACs, especially with ultrasound guidance 3, 6
• However, these studies have limited sample sizes and the current guidelines and FDA recommendations still advise discontinuation 1
• Ultrasound guidance appears to reduce the risk of bleeding complications during thoracentesis 3

Common Pitfalls and Caveats

• Failure to account for the last dose timing when planning the procedure date 2
• Inappropriate bridging with heparin products, which is not recommended for DOACs and may increase bleeding risk 2
• Resuming anticoagulation too early after the procedure, particularly if there were any procedural complications 2
• Not considering patient-specific factors that might affect drug clearance, such as drug interactions with P-gp inhibitors or strong CYP3A4 inhibitors 1

Remember that while the 48-hour discontinuation period is the standard recommendation, the decision should always consider the urgency of the procedure and the patient's thrombotic risk. In emergency situations where thoracentesis cannot be delayed, reversal agents may need to be considered.