From the Guidelines
For a patient with protein C deficiency who is taking Eliquis (apixaban) and needs to undergo electromyography (EMG) or nerve conduction studies (NCS), it is generally not necessary to hold Eliquis prior to the procedure. EMG/NCS are considered low bleeding risk procedures that involve small-gauge needle insertions with minimal tissue trauma, as indicated in the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1. The risk of clinically significant bleeding during these neurophysiologic tests is very low, even in patients on anticoagulation therapy. Patients with protein C deficiency are at increased risk for thrombosis, and interrupting anticoagulation could potentially increase their thrombotic risk. The benefit of continuing Eliquis to prevent thrombosis typically outweighs the minimal bleeding risk associated with EMG/NCS. Some key points to consider in this decision include:
- The patient's specific thrombotic risk factors
- The extent of the planned EMG (number of muscles to be sampled)
- Any additional bleeding risk factors the patient may have
- The results of studies such as the PAUSE (Perioperative Anticoagulation Use for Surgery Evaluation) study and the EMIT-AF/VTE (Edoxaban Management in Diagnostic and Therapeutic Procedures) study, which demonstrated low rates of major bleeding or thromboembolism with a DOAC interruption protocol 1. If there are concerns about bleeding risk, consultation between the neurologist performing the procedure and the physician managing the patient's anticoagulation is recommended to determine the optimal approach.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Protein C Deficiency and Anticoagulation
- Protein C deficiency is a condition that increases the risk of thrombotic events, and anticoagulation therapy is often necessary to manage this risk 2, 3.
- Traditional anticoagulant agents such as warfarin and heparin have been used to manage protein C deficiency, but direct oral anticoagulants (DOACs) like apixaban are being considered as alternative options 4, 5.
Use of Eliquis (Apixaban) in Protein C Deficiency
- There is limited evidence on the use of apixaban in patients with protein C deficiency, but a case series suggests that it may be effective in preventing recurrent thrombotic events without safety concerns 4.
- However, the evidence is not directly relevant to the question of whether to hold Eliquis for EMG/NCS, and more research is needed to determine the best approach for managing anticoagulation in patients with protein C deficiency undergoing procedures like EMG/NCS.
Management of Anticoagulation for Procedures
- In general, the management of anticoagulation for procedures like EMG/NCS depends on the individual patient's risk of thrombotic events and the potential risks of bleeding associated with the procedure 6, 3.
- Protein C concentrate may be used to prevent thromboembolic complications in patients with severe protein C deficiency while initiating oral anticoagulants, but its use in the context of EMG/NCS is not well established 6.