When should a patient restart Eliquis (apixaban) after it was stopped for 48 hours prior to dialysis catheter insertion?

Resuming Eliquis After Dialysis Catheter Insertion

Restart Eliquis 48-72 hours after dialysis catheter insertion once adequate hemostasis has been established. 1, 2

Timing of Resumption

For dialysis catheter insertion (a high bleeding risk procedure), resume apixaban 48-72 hours post-procedure when hemostasis is adequate. 1 The FDA label for apixaban states that the drug "should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established." 2

Key Considerations for Timing:

• Dialysis catheter insertion is classified as a high bleeding risk procedure due to central vein access, potential for bleeding into critical structures, and the need for ongoing catheter patency. 1

• The 48-72 hour window allows for:

  • Verification of adequate hemostasis at the insertion site 1
  • Assessment for any delayed bleeding complications 1
  • Completion of initial dialysis sessions to ensure catheter function 3

• Earlier resumption (24 hours) is reserved only for low bleeding risk procedures, which does not apply to central venous catheter insertion. 1

Clinical Assessment Before Resumption

Before restarting apixaban, verify the following:

• No active bleeding from the catheter insertion site or evidence of hematoma formation 1
• Stable hemodynamics without unexplained hypotension that could indicate occult bleeding 3
• Successful completion of at least one dialysis session without catheter dysfunction or bleeding complications 3
• No signs of central vein obstruction (ipsilateral upper extremity edema, facial swelling) that might require intervention 3

Dosing Upon Resumption

Resume apixaban at the patient's pre-procedure dose (either 5 mg twice daily or 2.5 mg twice daily based on dose-reduction criteria). 2

Special Considerations for Dialysis Patients:

• For patients on hemodialysis, the 2.5 mg twice daily dose is appropriate based on pharmacokinetic data showing drug accumulation in this population. 4 The standard 5 mg twice daily dose leads to supratherapeutic levels and should be avoided. 4

• Apixaban is minimally removed by dialysis (only 4% cleared during a dialysis session), so timing relative to dialysis sessions is not critical. 4

• No bridging anticoagulation is needed when resuming apixaban, as therapeutic anticoagulation is achieved within 2-4 hours of administration. 1, 5

Common Pitfalls to Avoid

• Do not resume apixaban within 24 hours of catheter insertion, as this significantly increases bleeding risk without adequate time to assess hemostasis. 1

• Do not use bridging therapy with heparin or LMWH when restarting apixaban, as this increases bleeding risk without reducing thrombotic events. 1

• Do not use the 5 mg twice daily dose in dialysis patients unless they were on this dose pre-procedure for specific indications, as it leads to drug accumulation. 4

• Avoid resuming anticoagulation if there are signs of catheter-related complications such as infection (fever, rigors), dysfunction (inability to achieve adequate blood flow), or central vein obstruction. 3

Balancing Thrombotic vs. Bleeding Risk

The decision to resume at 48 vs. 72 hours depends on individual bleeding risk assessment:

• Resume at 48 hours if hemostasis is clearly established, no bleeding complications occurred, and the patient has high thrombotic risk (e.g., recent stroke, mechanical heart valve, recurrent VTE). 1

• Delay until 72 hours if there were any intraoperative bleeding concerns, the patient required multiple catheter placement attempts, or baseline bleeding risk is elevated (thrombocytopenia, recent major bleeding). 1

• Recent data suggests apixaban reduces recurrent thrombosis risk in hemodialysis vascular access (24.0% vs. 40.8% in controls), supporting resumption once safe to do so. 6