Apixaban Hold Duration for Ascitic Drain
Hold Eliquis (apixaban) for 3 days (72 hours) before an ascitic drain procedure.
Rationale for 3-Day Hold
Ascitic drain/paracentesis is classified as a high bleeding risk procedure based on established gastroenterology guidelines, which necessitates the longer discontinuation period 1.
The British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy specifically recommend that the last dose of apixaban be taken 3 days before high-risk procedures 1.
This 3-day window corresponds to 4-5 half-lives of apixaban (half-life ~12 hours), achieving minimal residual anticoagulant effect 2.
The French Working Group on Perioperative Hemostasis similarly recommends interrupting apixaban 3 days before high bleeding risk invasive procedures 1.
Bleeding Risk Classification
Ascitic drainage carries significant hemorrhage risk due to:
- Potential for intra-abdominal bleeding in patients with portal hypertension and coagulopathy 3
- Risk of abdominal wall hematoma formation (documented in 5% of cases even without anticoagulation) 3
- Vascular nature of the peritoneal cavity in cirrhotic patients 3
Critical Renal Function Consideration
You must assess renal function before determining the hold period:
- For patients with normal renal function (CrCl >50 mL/min): Hold for 3 days 1, 2
- For patients with moderate renal impairment (CrCl 30-50 mL/min): Consider extending to 4 days, as apixaban clearance is prolonged 4
- Apixaban has 27% renal clearance, making renal function assessment mandatory 2, 5
Practical Implementation
The FDA-approved drug label states apixaban should be discontinued at least 48 hours prior to procedures with moderate or high risk of bleeding 6. However, the guideline-based 3-day recommendation takes precedence for high-risk procedures like ascitic drainage 1.
Timing specifics:
- If patient takes apixaban twice daily, the last dose should be 3 full days before the procedure 1
- This means skipping 6 doses total for a twice-daily regimen 2
Common Pitfalls to Avoid
- Do not use the 48-hour hold recommended for low-risk procedures—ascitic drainage is high-risk 1
- Do not bridge with heparin—bridging increases bleeding risk without reducing thrombotic events and is not indicated for DOACs 1
- Do not rely on INR or aPTT to assess apixaban effect—these are unreliable indicators 1
- Do not assume all paracentesis procedures are the same—continuous drainage over 72 hours may warrant even more caution 3
Resumption After Procedure
Resume apixaban 2-3 days after the ascitic drain once adequate hemostasis is established 1, 2. The rapid onset of action (full effect within 3 hours) means no loading dose is needed 1.