Stopping Eliquis Before Dialysis Catheter Insertion
Stop Eliquis (apixaban) 48 hours before dialysis catheter insertion, with the last dose taken 2 days prior to the procedure. 1
Recommended Timing Based on FDA Labeling and Guidelines
The FDA label for apixaban explicitly states that the drug should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of bleeding. 1
Dialysis catheter insertion qualifies as a moderate-to-high bleeding risk procedure based on the vascular access nature and potential for significant hemorrhage. 2
For patients with normal renal function (CrCl >30 mL/min), the standard 48-hour interruption is appropriate, as apixaban has a half-life of approximately 12 hours and requires 4-5 half-lives for adequate clearance. 3
Special Considerations for Dialysis Patients
Patients with severe renal impairment or those already on dialysis may have prolonged apixaban clearance, though apixaban is less renally dependent than other DOACs like dabigatran. 4, 5
In dialysis patients, consider extending the interruption period to 72 hours (3 days) before catheter insertion, particularly if there are additional bleeding risk factors such as thrombocytopenia or recent antiplatelet use. 2, 6
Check baseline coagulation parameters before the procedure, as failure to do so has been associated with bleeding complications in catheter insertion studies. 2
Critical Pitfalls to Avoid
Never use bridging anticoagulation with heparin or LMWH when stopping apixaban for dialysis catheter insertion—this dramatically increases bleeding risk without reducing thrombotic risk. 4, 3
Do not assume the morning dose on the day of surgery is safe to give; the last dose should be at least 48 hours before the procedure to minimize residual anticoagulant effect. 4, 1
Avoid catheter insertion if there is any uncertainty about when the last apixaban dose was taken, as residual anticoagulation significantly increases bleeding complications. 2
Resumption After Catheter Insertion
Resume apixaban at least 6 hours after the procedure if hemostasis is adequate and there is no ongoing bleeding, though waiting 24-48 hours is prudent for a vascular access procedure. 3, 1
For twice-daily dosing, restart with the evening dose on the day of the procedure only if hemostasis is completely secure; otherwise delay until the following day. 7, 3
The FDA label recommends restarting apixaban "as soon as adequate hemostasis has been established" without specifying an exact timeframe, emphasizing clinical judgment regarding bleeding control. 1
Additional Risk Mitigation
Hold anticoagulation for a minimum of 24 hours postoperatively to reduce bleeding risk, as bleeding complications are typically associated with perioperative anticoagulation. 2
Correct any coagulopathy, thrombocytopenia, or uremic platelet dysfunction before proceeding with catheter insertion, as these factors compound the bleeding risk from residual apixaban. 2
The major bleeding complication rate for dialysis catheter insertion is approximately 2% when anticoagulation is appropriately managed. 2