Is it safe to hold apixaban (Eliquis) and clopidogrel (Plavix) therapy in a patient with stents to obtain a biopsy?

Safety of Holding Apixaban and Clopidogrel for Biopsy in a Patient with Stents

Temporarily holding apixaban (Eliquis) and clopidogrel (Plavix) for a biopsy procedure in a patient with coronary stents carries significant risk of stent thrombosis and should only be considered after careful risk assessment and with appropriate bridging strategies in place.

Risk Assessment for Antiplatelet/Anticoagulant Interruption

• The risk of stent thrombosis is highest when both antiplatelet agents are discontinued simultaneously, particularly in patients with recent stent placement 1
• Stent thrombosis can be catastrophic, leading to myocardial infarction, cardiogenic shock, and death 1
• The timing since stent placement is critical - risk is highest within the first 30 days for bare-metal stents and within the first year for drug-eluting stents 1, 2
• For drug-eluting stents, clopidogrel should be continued for at least 3 months for sirolimus-eluting stents and 6 months for paclitaxel-eluting stents, ideally up to 12 months 1

Recommendations for Biopsy Procedure

• If the biopsy is elective and non-urgent, it should be delayed until at least 12 months after stent placement when possible 2
• For apixaban, discontinuation should occur at least 48 hours prior to procedures with moderate to high bleeding risk, and at least 24 hours prior to procedures with low bleeding risk 3
• For clopidogrel, if interruption is absolutely necessary, consider the following approach:
  • Maintain aspirin therapy during the procedure if possible, as this provides some protection against stent thrombosis 1
  • If both agents must be discontinued, limit the interruption period to the shortest time possible 1, 2
  • Consider bridging with low-molecular-weight heparin during the perioperative period 2

Special Considerations for This Patient

• The patient's desire for "aggressive" treatment of their disease must be balanced against the risk of catastrophic stent thrombosis 1
• The upcoming cardiology follow-up (10/24/2025) provides an opportunity for a comprehensive risk assessment by the cardiologist before proceeding with biopsy 1
• If the biopsy is urgent and cannot be delayed until after the cardiology consultation, consider:
  • Consulting with the cardiologist immediately to develop a personalized bridging strategy 1
  • Maintaining at least one antiplatelet agent (preferably aspirin) during the procedure if the bleeding risk allows 1, 2
  • Using a bridging protocol with parenteral anticoagulants if both oral agents must be discontinued 3

Potential Bridging Strategies

• For patients at high risk of thrombosis but requiring temporary discontinuation of oral anticoagulants:
  • Transition to shorter-acting drugs such as heparin or low-molecular-weight heparin may be appropriate 1
  • Resume the oral antiplatelet and anticoagulant therapy as soon as adequate hemostasis has been established after the biopsy 3
• For patients with drug-eluting stents, continuing aspirin during the procedure is the preferred option when possible 2

Conclusion

• The safest approach would be to delay the biopsy until after the cardiology consultation on 10/24/2025 1
• If the biopsy cannot be delayed, a careful bridging strategy should be implemented in consultation with the patient's cardiologist 1, 3
• The risk of stent thrombosis must be weighed against the risk of bleeding during the biopsy procedure, with consideration given to the time since stent placement and the type of stent 1, 2