When should I hold Eliquis (apixaban) for a patient undergoing an interventional radiology (IR) procedure for replacement of a chest catheter (CCY) drain?

Apixaban Hold Duration for IR Cholecystostomy Drain Replacement

Hold apixaban for a minimum of 48 hours before the IR procedure for cholecystostomy drain replacement in patients with normal renal function (CrCl >50 mL/min). 1, 2

Risk Classification

Cholecystostomy drain replacement is classified as a moderate hemorrhagic risk procedure where surgical hemostasis may be challenging and a window without anticoagulation is necessary. 3

Hold Duration Based on Renal Function

Standard patients (CrCl >50 mL/min):

• Hold apixaban for 48 hours minimum before the procedure 1, 2
• For twice-daily dosing: last dose should be the morning of the day before the procedure 3
• For once-daily morning dosing: last dose should be the morning of the day before the procedure 3
• For once-daily evening dosing: last dose should be two days before the procedure 3

Impaired renal function (CrCl 30-50 mL/min):

• Extend the hold to 72 hours (3 days) to account for reduced drug clearance 2, 3
• This longer duration is critical because apixaban has approximately 27% renal elimination, and reduced clearance increases bleeding risk 2

Essential Pre-Procedure Assessment

Calculate creatinine clearance using the Cockcroft-Gault formula before determining hold duration—this is mandatory, not optional. 3, 2 Recent creatinine levels must be available. 3

Screen for drug interactions:

• Check for P-glycoprotein (P-gp) inhibitors (e.g., verapamil, amiodarone) 3, 2
• Check for strong CYP3A4 inhibitors (e.g., ketoconazole, ritonavir) 3, 2
• If patient is taking combined P-gp and CYP3A4 inhibitors, extend the hold period by an additional 24 hours 2

Bridging Anticoagulation

Do not use heparin bridging (UFH or LMWH) for this procedure. 3, 2 Bridging increases major bleeding risk without reducing thromboembolic events in most patients. 2, 4 The only exception would be patients at very high thrombotic risk, which requires multidisciplinary discussion. 3

Biological Monitoring

Do not routinely measure apixaban concentration before the procedure. 3, 2 The objective is to avoid high plasma concentrations during the procedure, not to achieve negligible concentrations. 3 Standard coagulation tests (INR, aPTT) are not useful for monitoring apixaban effect. 2

Post-Procedure Resumption

Resume apixaban at least 6 hours after the procedure once adequate hemostasis is confirmed. 1, 2

For moderate bleeding risk procedures like drain replacement:

• If hemostasis is secure: resume at 6 hours 1, 2
• If there is concern about bleeding or surgical contraindication: delay resumption to 24-48 hours postoperatively 2
• Return to the regular twice-daily dosing schedule 4

If venous thromboprophylaxis is needed during the delay:

• Use UFH or LMWH at least 6 hours after the procedure 3
• Administer the first therapeutic dose of apixaban 12 hours after the last prophylactic LMWH dose 3

Common Pitfalls to Avoid

Do not assume 24 hours is sufficient—IR drain procedures require at least 48 hours for standard patients. 2, 1

Do not skip renal function assessment—impaired clearance (CrCl 30-50 mL/min) mandates 72 hours, not 48 hours. 3, 2

Do not bridge with heparin routinely—this increases bleeding without reducing thrombotic events. 3, 2, 4

Do not resume apixaban prematurely—confirm adequate hemostasis before restarting anticoagulation. 2, 1

Do not ignore drug interactions—P-gp and CYP3A4 inhibitors require extended hold periods beyond the standard 48 hours. 3, 2