Should I hold Eliquis (apixaban) before an invasive procedure due to a significant risk of bleeding?

Should You Hold Eliquis Before an Invasive Procedure?

Yes, you should hold Eliquis (apixaban) before invasive procedures, with the timing based on the bleeding risk of the procedure: discontinue at least 48 hours before moderate-to-high bleeding risk procedures and at least 24 hours before low bleeding risk procedures. 1

Timing Based on Bleeding Risk

Low Bleeding Risk Procedures

• Hold for 24 hours minimum before procedures with low bleeding risk or where bleeding would be non-critical and easily controlled 1
• For twice-daily regimens, take the last dose on the morning of the day before the procedure 2, 3
• For once-daily morning regimens, take the last dose on the morning of the day before the procedure 3
• For once-daily evening regimens, take the last dose two days before the procedure 2, 3

Moderate-to-High Bleeding Risk Procedures

• Hold for 48 hours minimum before procedures with moderate or high risk of unacceptable or clinically significant bleeding 1
• For standard bleeding risk procedures, discontinue apixaban 3 days before the procedure (when creatinine clearance >30 mL/min) 2, 3
• This 3-day interruption applies to all "xaban" drugs (apixaban, rivaroxaban, edoxaban) due to their similar pharmacokinetic profiles 2

Very High Bleeding Risk Procedures

• Hold for up to 5 days before very high hemorrhagic risk procedures such as intracranial neurosurgery or neuraxial anesthesia/spinal puncture 2
• The entire French Working Group strongly recommends against performing spinal or epidural anesthesia in patients with possible residual apixaban concentration 2

Critical Considerations

Patient-Specific Factors

• Check renal function before determining hold duration, as this affects drug clearance 2, 4
• Consider age and concomitant medications (P-glycoprotein inhibitors, CYP3A4 inhibitors) that may increase apixaban plasma concentrations and require longer hold times 2

Bridging Anticoagulation

• Do NOT bridge with heparin during the 24-48 hour hold period before procedures 2, 3, 4
• Bridging is not generally required and increases bleeding risk without reducing thrombotic events 3, 4
• The objective is to avoid high plasma concentrations during the procedure, not to achieve negligible concentrations 2

Resumption After Procedure

Standard Resumption Protocol

• Resume at least 6 hours after the procedure once adequate hemostasis is achieved 2, 3, 1
• For twice-daily regimens, resume the evening of the same day if hemostasis is adequate 2
• Return to the regular twice-daily dosing schedule immediately 3, 4

Delayed Resumption

• Delay resumption if there is ongoing bleeding or any surgical contraindication 2, 3
• In cases of delayed resumption, consider appropriate thromboprophylaxis (mechanical or pharmacologic) based on the patient's thrombotic risk 2, 3

Common Pitfalls to Avoid

• Do not perform neuraxial anesthesia without ensuring adequate discontinuation time, as spinal/epidural hematomas can result in permanent paralysis 1
• Do not use bridging anticoagulation for routine procedures, as this significantly increases bleeding risk 3, 4
• Do not resume full-dose anticoagulation too early after high bleeding risk surgery 3
• Do not ignore renal function when calculating hold duration, especially in elderly patients 2, 4
• Confirm adequate hemostasis before resuming apixaban to prevent postoperative bleeding complications 3, 4