Can a patient on Eliquis (apixaban) safely undergo a nontraumatic eye injection without interrupting anticoagulation therapy?

Eye Injections on Eliquis: Continue Anticoagulation

For patients on Eliquis (apixaban) requiring nontraumatic eye injections (intravitreal injections), anticoagulation should be continued without interruption. 1

Rationale for Continuing Anticoagulation

Eye procedures, particularly intravitreal injections and cataract surgery, are classified as minimal bleeding risk procedures where bleeding is unlikely or would be inconsequential if it occurred. 1 The ACC/AHA guidelines explicitly state that eye surgery, particularly for cataracts or glaucoma, is usually associated with very little bleeding and is frequently performed without alteration of anticoagulation therapy. 1

The risk of thromboembolic events from stopping anticoagulation outweighs the minimal bleeding risk associated with eye injections. 1

Specific Management Protocol

Continue Apixaban at Full Dose

• Do not hold or reduce the apixaban dose before the eye injection 1
• Maintain the patient's regular dosing schedule (typically 5 mg twice daily or 2.5 mg twice daily for dose-reduced patients) 1
• No bridging anticoagulation is needed or recommended 2

Procedure Timing Considerations

• Schedule the injection at the midpoint between apixaban doses when possible to minimize peak anticoagulant effect 3
• For patients on twice-daily dosing, this would be approximately 6 hours after the morning dose 3

Evidence Supporting This Approach

The literature review on perioperative management of ophthalmic patients demonstrates that routine intravitreal injections can be safely performed while continuing all antithrombotic agents, including DOACs like apixaban. 4 While hemorrhagic complications can occur with any eye procedure, the rates are acceptably low and do not justify the thromboembolic risk of stopping anticoagulation. 4

For minimal bleeding risk procedures like intravitreal injections, the standardized perioperative DOAC management protocol allows continuation of the medication or, at most, holding it on the day of the procedure only. 3 However, given the extremely low bleeding risk of intravitreal injections, continuation is preferred. 1

Critical Pitfalls to Avoid

• Do not stop apixaban for several days before the injection - this creates unnecessary thromboembolic risk without meaningful bleeding risk reduction 1, 3
• Do not use bridging anticoagulation - this increases bleeding risk without reducing thrombotic risk and is never indicated for DOAC interruption 2
• Do not check anti-Xa levels or coagulation studies - these are not needed for elective minimal-risk procedures 3

Post-Procedure Management

• Resume normal activities and apixaban dosing schedule immediately after the injection 1
• Monitor for any signs of intraocular hemorrhage (decreased vision, floaters, eye pain) 5
• If significant bleeding occurs, assess severity and consider temporary discontinuation only if major bleeding criteria are met (hemodynamic instability, hemoglobin drop ≥2 g/dL, or critical site bleeding) 6

Special Considerations

While DOACs like apixaban have been associated with ocular bleeding complications including submacular hemorrhage and vitreous hemorrhage, these are rare events. 5 The risk of stopping anticoagulation (stroke, systemic embolism, or VTE recurrence) is substantially higher than the risk of clinically significant bleeding from an intravitreal injection. 1, 3

The ACC/AHA guidelines make clear that antithrombotic therapy should not be stopped for procedures where bleeding would be inconsequential, and eye injections fall squarely into this category. 1