Eliquis Management for Bronchoscopy with Biopsy
Hold Eliquis (apixaban) for 48 hours before bronchoscopy with biopsy, as this is a procedure with moderate to high bleeding risk.
Procedural Bleeding Risk Classification
Bronchoscopy with biopsy, particularly transbronchial biopsy, is classified as a moderate to high-risk bleeding procedure based on:
- Hemorrhage occurs in approximately 9% of transbronchial biopsy cases 1
- Pneumothorax risk of 1-5% with transbronchial biopsy 1
- Overall major complication rate of 6.8% 1
Specific Holding Period for Apixaban
The FDA label for apixaban provides clear guidance on pre-procedural discontinuation:
- Discontinue apixaban at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of unacceptable or clinically significant bleeding 2
- Discontinue at least 24 hours prior only for procedures with low bleeding risk or where bleeding would be non-critical and easily controlled 2
Given that transbronchial biopsy carries a 9% hemorrhage risk and bleeding in the airway can have serious consequences even in small amounts 3, the 48-hour holding period is appropriate.
Pharmacokinetic Rationale
The 48-hour holding period aligns with apixaban's pharmacokinetic profile:
- Half-life of approximately 12 hours 4
- Peak concentration occurs 3-4 hours after oral administration 4
- Approximately 27% of clearance occurs via renal excretion 4
After 48 hours (approximately 4 half-lives), apixaban levels are sufficiently reduced to minimize bleeding risk.
Pre-Procedure Laboratory Testing
Before proceeding with transbronchial biopsy:
- Check platelet count, prothrombin time, and partial thromboplastin time before performing transbronchial biopsies 1, 5
- This applies even after appropriate holding periods to ensure adequate hemostasis
Resumption of Anticoagulation
- Restart apixaban after the procedure as soon as adequate hemostasis has been established 2
- No bridging anticoagulation is generally required during the 48-hour period after stopping apixaban 2
Important Caveats
Do not confuse bronchoscopy with biopsy versus simple bronchoscopy without biopsy. The British Thoracic Society guidelines from 2001 1 recommend checking coagulation parameters only when transbronchial biopsy is anticipated, recognizing the substantially higher bleeding risk with tissue sampling compared to diagnostic bronchoscopy alone.
Renal function matters. While the standard 48-hour holding period applies to most patients, those with severe renal impairment may require longer discontinuation periods due to reduced clearance 4, though specific guidance for this scenario should be individualized based on creatinine clearance.
Post-procedure monitoring is critical. A chest radiograph should be obtained at least 1 hour after transbronchial biopsy to exclude pneumothorax 1, 5, and patients should receive written instructions about the possibility of delayed pneumothorax 5.