Holding Eliquis (Apixaban) Prior to Epidural Procedures
For epidural procedures, hold Eliquis (apixaban) for at least 72 hours (3 days) prior to the procedure when creatinine clearance is >30 mL/min, as neuraxial anesthesia carries very high hemorrhagic risk requiring complete drug elimination. 1
Procedure Risk Classification
Epidural anesthesia and neuraxial punctures are classified as very high hemorrhagic risk procedures that require the longest interruption time for direct oral anticoagulants (DOACs). 1 This classification is more stringent than standard high-risk surgeries due to the catastrophic consequences of epidural hematoma, which can result in permanent paralysis.
Specific Timing for Apixaban Discontinuation
Standard Renal Function (CrCl >30 mL/min)
- Hold apixaban for 3 days (72 hours) before the epidural procedure 1
- The last dose should be taken 3 days prior to the procedure (with day 0 being the procedure day) 1
Considerations for Extended Hold Times
- For neuraxial procedures specifically, consider holding up to 5 days in patients with additional risk factors 1
- The French Working Group on Perioperative Hemostasis emphasizes that neuraxial procedures need longer interruption times than other high-risk surgeries 1
Critical Safety Warnings
Absolute Contraindications
Never perform spinal or epidural anesthesia if there is any possible residual DOAC concentration, particularly in: 1
- Patients over 80 years of age on any DOAC
- Patients with renal impairment
- Situations where insufficient discontinuation time has elapsed
Factors That Increase Drug Accumulation
The following require even longer hold times beyond the standard 72 hours: 1
- P-glycoprotein inhibitors (which affect all DOACs including apixaban)
- CYP3A4 inhibitors (which specifically affect apixaban metabolism)
- Advanced age (>80 years)
- Renal dysfunction (though apixaban is less renally cleared than dabigatran)
No Bridging Required
Do not use bridging anticoagulation with heparin or low-molecular-weight heparin (LMWH) when stopping apixaban. 2 Bridging therapy increases bleeding risk without reducing thrombotic risk and is specifically contraindicated for DOAC interruption. 2
Resumption After Epidural Procedure
Timing for Restarting Apixaban
- Resume apixaban 6-48 hours after the procedure depending on bleeding risk and adequacy of hemostasis 2
- For procedures with adequate hemostasis, resumption can occur as early as 6 hours post-procedure 2
- If epidural catheter remains in place, additional precautions are required for catheter removal timing
Epidural Catheter Management
When an epidural catheter is left in situ: 1
- The catheter should be removed at least 12 hours after the last LMWH dose (if any prophylactic anticoagulation is used)
- Wait at least 2 hours after catheter removal before administering the first dose of any anticoagulant 1
- Apixaban should not be restarted until the catheter is removed and the 2-hour safety window has passed
Common Pitfalls to Avoid
Do not use the 24-48 hour hold time recommended for standard high-risk surgeries—epidurals require the full 72-hour hold 1, 2
Do not rely on the FDA label's general 48-hour recommendation for moderate-to-high bleeding risk procedures, as this does not specifically address the unique risks of neuraxial procedures 3
Do not perform the procedure if recent creatinine clearance is unavailable, as renal function directly impacts drug elimination 1
Do not assume all DOACs have the same hold times—dabigatran requires even longer holds (4-5 days) due to predominant renal elimination 2
Pharmacokinetic Rationale
Apixaban has a half-life of approximately 12 hours, with peak concentration occurring 3-4 hours after oral administration. 4 The 72-hour hold time allows for approximately 6 half-lives to elapse, ensuring >98% drug elimination before the high-risk neuraxial procedure. 4 This extended timeframe accounts for the zero-tolerance approach required for epidural procedures where even minimal anticoagulant effect could result in devastating neurological complications.