Management of Patients on Apixaban (Eliquis) Requiring Incision and Drainage
For patients on Eliquis (apixaban) who need an incision and drainage (I&D) procedure, the medication should be discontinued at least 24 hours prior to the procedure if it's considered low bleeding risk, or 48 hours prior if moderate to high bleeding risk.
Laboratory Tests to Order
- Complete blood count (CBC) to assess baseline hemoglobin, hematocrit, and platelet count 1
- Renal function tests including creatinine and calculation of creatinine clearance (CrCl) using the Cockcroft-Gault formula, as this determines the appropriate timing of apixaban discontinuation 1
- Coagulation profile including PT/INR, though specific apixaban levels are not routinely needed 1
Timing of Apixaban Discontinuation Before I&D
For Low Hemorrhagic Risk I&D Procedures:
- For twice daily regimen (standard apixaban dosing): Last dose should be taken on the morning of the day before the procedure 1
- For once daily regimen with morning intake: Last dose should be on the morning of the day before the procedure 1
- For once daily regimen with evening intake: Last dose should be two days before the procedure 1
- This corresponds to approximately 24 hours without apixaban before the procedure 2
For High Hemorrhagic Risk I&D Procedures:
- Discontinue apixaban at least 48 hours prior to the procedure 2
- For patients with renal impairment (CrCl 30-50 mL/min), consider longer discontinuation periods 1
Bridging Anticoagulation
- Preoperative bridging with heparin (UFH or LMWH) is generally not recommended for patients on apixaban 1
- There is no need for routine biological monitoring of apixaban levels before the procedure 1
Resumption of Apixaban After I&D
For low bleeding risk procedures with adequate hemostasis, apixaban can be resumed at least 6 hours after the end of the procedure 1
For twice daily regimen: Resume the evening of the same day as the procedure 1
For once daily regimen with morning intake: Resume the next morning 1
For once daily regimen with evening intake: Resume the evening of the procedure day 1
If there is ongoing bleeding or surgical contraindication, delay resumption and consider venous thromboprophylaxis according to the patient's thromboembolic risk 1
Special Considerations
- For patients with higher bleeding risk or incomplete hemostasis, therapeutic anticoagulation should be delayed for 24-72 hours postoperatively 1
- If the patient has recently experienced a venous thromboembolic event and is on higher doses of apixaban, a personalized approach should be discussed by a multidisciplinary team 1
- Creatinine clearance should be monitored postoperatively if the procedure or patient's condition could affect renal function 1
Common Pitfalls to Avoid
- Failing to assess renal function before determining the appropriate discontinuation period 1
- Unnecessary bridging with heparin products, which can increase bleeding risk without reducing thrombotic risk 1
- Resuming full-dose anticoagulation too early in cases with incomplete hemostasis 1
- Not considering drug interactions that may increase apixaban plasma concentrations (P-glycoprotein inhibitors and CYP3A4 inhibitors) 1
By following these guidelines, clinicians can minimize both bleeding complications and thrombotic events in patients on apixaban requiring I&D procedures.