Does apixaban (Eliquis) need to be held for paracentesis?

From the Guidelines

Apixaban (Eliquis) should be held for at least 1 day before paracentesis for low-to-moderate-bleed-risk procedures and 2 days before high-bleed-risk procedures, as recommended by the American College of Chest Physicians clinical practice guideline. This management approach can be applied irrespective of whether patients are receiving apixaban for atrial fibrillation or VTE 1. The decision to hold apixaban should be individualized based on the patient's specific circumstances, weighing the risk of bleeding against the risk of thrombotic events from temporarily stopping anticoagulation.

When considering the risk of bleeding complications during paracentesis, it is essential to note that the procedure itself has a low risk of bleeding, with complications reported in only about 1% of patients, and more serious complications, such as hemoperitoneum or bowel entry by the paracentesis needle, are rare (1/1000 paracenteses) 1. However, the presence of renal failure may increase the risk of bleeding, and caution should be exercised in these patients.

Key considerations for holding apixaban before paracentesis include:

• The type of procedure (low-to-moderate-bleed-risk or high-bleed-risk)
• The patient's kidney function
• The assessed bleeding risk
• The individual patient's thrombotic and bleeding risks

After the procedure, apixaban can usually be resumed 24-48 hours later if there are no signs of bleeding. The timing of discontinuation and resumption should ultimately be determined by the healthcare provider performing the procedure in consultation with the provider who prescribed the anticoagulant.

From the FDA Drug Label

2.3 Temporary Interruption for Surgery and Other Interventions 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)].

Paracentesis is considered a procedure with a low to moderate risk of bleeding.

• The label does not explicitly state the required time to hold apixaban for paracentesis.
• However, based on the information provided for low risk of bleeding procedures, apixaban tablets should be discontinued at least 24 hours prior to the procedure.
• It is essential to note that the decision to hold apixaban should be made on a case-by-case basis, considering the individual patient's risk of bleeding and thrombosis 2.

From the Research

Apixaban and Paracentesis

• The need to hold apixaban (Eliquis) for paracentesis is not explicitly stated in the provided studies, but several studies discuss the risk of bleeding associated with paracentesis in patients with chronic liver disease and coagulopathy 3, 4, 5, 6.
• A study published in 2023 reports two cases of major bleeding after paracentesis in patients taking apixaban, suggesting that apixaban use may be associated with an increased risk of bleeding complications during paracentesis 7.
• Another study found that the overall risk of major bleeding after abdominal paracentesis is low in patients with chronic liver disease and coagulopathy, but notes that thromboelastography (TEG) may be used to predict bleeding risk and guide transfusion requirements 4.
• Real-time ultrasound-guided paracentesis by radiologists has been shown to have a near zero risk of hemorrhage without correction of coagulopathy, with significant post-paracentesis hemorrhage occurring in only 0.19% of patients 6.

Bleeding Risk Factors

• Several studies identify risk factors for bleeding complications after paracentesis, including low platelet count, Child-Pugh stage C, and alcoholic cirrhosis 4, 5.
• The use of apixaban in patients with cirrhosis and moderate renal impairment may also increase the risk of bleeding complications during paracentesis 7.
• However, one study found that no predictors of post-procedure bleeding were found, including INR and platelet count, when paracentesis was performed with real-time ultrasound guidance by radiologists 6.

Clinical Implications

• The studies suggest that paracentesis can be safely performed in patients with chronic liver disease and coagulopathy, but caution should be exercised when using anticoagulants like apixaban 3, 4, 5, 6, 7.
• Further investigation into the safety of paracentesis in patients with cirrhosis on apixaban may be warranted, as well as additional understanding of the clinical safety of this drug in Child-Pugh B cirrhosis 7.