From the Guidelines
Holding apixaban for 5 days before a TURP procedure is a reasonable approach, considering the high bleeding risk associated with this procedure. For apixaban, which has a half-life of approximately 7-8 hours, discontinuation 2-3 days before low bleeding risk procedures and 3-5 days before high bleeding risk procedures like TURP is typically recommended, as suggested by 1. The 5-day hold requested by the urologist is at the conservative end of this range, which is reasonable for a TURP procedure since it carries significant bleeding risk due to the highly vascular nature of the prostate. This timing allows for adequate clearance of the anticoagulant effect, reducing the risk of perioperative bleeding complications. For patients with normal renal function, most of the anticoagulant effect will be eliminated after 3-4 half-lives (21-28 hours), but the full 5 days provides additional safety margin, as supported by the more recent guideline from 1. If the patient has renal impairment, this extended hold period becomes even more important as drug clearance may be delayed. After the procedure, apixaban can typically be resumed 24-48 hours later, depending on the patient's postoperative bleeding risk assessment. Some key points to consider in the management of anticoagulation in patients undergoing TURP include:
- The pharmacokinetic properties of the specific anticoagulant being used
- The patient's renal function and potential for drug accumulation
- The bleeding risk associated with the procedure
- The need for individualized management strategies based on patient-specific factors, as emphasized by 1.
From the FDA Drug Label
Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.
A 5-day hold is not typical for holding a DOAC prior to TURP. The recommended duration for holding apixaban prior to elective surgery or invasive procedures is at least 48 hours for procedures with a moderate or high risk of bleeding, and at least 24 hours for procedures with a low risk of bleeding. 2
From the Research
Holding DOAC Prior to TURP Procedure
- The provided studies do not directly address the typical timing for holding a Direct Oral Anticoagulant (DOAC) prior to a Transurethral Resection of the Prostate (TURP) procedure.
- However, studies such as 3 and 4 discuss the safety and efficacy of apixaban in patients with renal impairment, which may be relevant to patients undergoing TURP.
- Another study, 5, evaluates the use of rivaroxaban and apixaban for the treatment of suspected or confirmed heparin-induced thrombocytopenia, but does not provide information on holding DOACs prior to TURP.
- Studies 6 and 7 focus on the use of low-molecular-weight heparin and target-specific oral anticoagulants for thromboprophylaxis in medically ill patients, but do not address the specific question of holding DOACs prior to TURP.
Clinical Considerations
- The decision to hold a DOAC prior to a TURP procedure should be based on individual patient factors, such as bleeding risk and renal function.
- Clinicians should consult current guidelines and evidence-based recommendations for the management of anticoagulation in patients undergoing surgical procedures.
- The provided studies do not offer direct guidance on the optimal timing for holding apixaban prior to TURP, and therefore, clinicians should exercise caution and consider individual patient factors when making decisions about anticoagulation management.