From the Guidelines
I recommend holding the evening dose of Eliquis (apixaban) before tomorrow's wound debridement procedure. For elective procedures with moderate bleeding risk like debridement, Eliquis should typically be held for at least 24 hours prior to the procedure, as suggested by the 2016 study in Circulation 1. Since the patient just started Eliquis this morning and has the procedure scheduled for 7am tomorrow, holding tonight's dose would be appropriate to minimize bleeding risk during the procedure. The patient was previously on a heparin drip, which has a much shorter half-life than Eliquis. Eliquis has a half-life of approximately 12 hours and can significantly increase bleeding risk during invasive procedures. According to the study in Blood 1, for patients with normal or mild renal impairment, the last dose of apixaban should be given 2 days before surgery, which in this case would be holding the dose tonight. After the procedure, Eliquis can generally be resumed 24-48 hours later, depending on the assessed bleeding risk post-debridement. Be sure to communicate this plan with the surgical team performing the debridement and document the decision to hold anticoagulation in the patient's chart.
Some key points to consider:
- The half-life of apixaban is approximately 12 hours, and it can significantly increase bleeding risk during invasive procedures.
- The patient's renal function is not specified, but assuming normal or mild impairment, holding the dose tonight would be appropriate.
- The 2012 study in Chest 1 provides guidance on perioperative management of antithrombotic therapy, but the 2016 study in Circulation 1 provides more specific guidance on the management of non-vitamin K antagonist oral anticoagulants like apixaban.
- It is essential to communicate the plan to hold anticoagulation with the surgical team and document the decision in the patient's chart.
In terms of resuming anticoagulation after the procedure, the decision should be based on the assessed bleeding risk post-debridement, as suggested by the study in Circulation 1. The patient's renal function and other individual factors should also be taken into consideration when determining the timing of resuming anticoagulation.
From the FDA Drug Label
If apixaban tablets are discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant The pharmacodynamic effect of apixaban tablets can be expected to persist for at least 24 hours after the last dose, i.e., for about two drug half-lives. Indwelling epidural or intrathecal catheters should not be removed earlier than 24 hours after the last administration of apixaban tablets The next dose of apixaban tablets should not be administered earlier than 5 hours after the removal of the catheter.
The patient is scheduled to have a wound debridement tomorrow at 7am. To minimize the risk of bleeding, it is recommended to hold the eliquis (apixaban) for tonight and consider alternative anticoagulant coverage if necessary, as the procedure may pose a risk of bleeding and the pharmacodynamic effect of apixaban can persist for at least 24 hours after the last dose 2.
From the Research
Wound Debridement and Anticoagulation Management
The patient is scheduled to have a wound debridement tomorrow at 7am and is currently on Eliquis (apixaban) after being on a heparin drip. The question is whether to hold the Eliquis for tonight.
Considerations for Debridement
- Debridement is a crucial step in wound healing, and its timing should be considered in relation to anticoagulation therapy 3, 4, 5, 6.
- There is limited evidence on the specific management of anticoagulation in patients undergoing wound debridement, but it is essential to balance the risk of bleeding with the risk of thrombosis 7.
Anticoagulation Management
- Apixaban (Eliquis) is a direct factor Xa inhibitor that can be used for the prevention of thrombosis in patients with atrial fibrillation and for the treatment of heparin-induced thrombocytopenia 7.
- The decision to hold or continue anticoagulation therapy should be made on a case-by-case basis, considering the patient's individual risk factors and the type of surgery or procedure they are undergoing.
Recommendations
- Consult with the attending physician (Chengat) and the surgical team to determine the best course of action for the patient's anticoagulation management in relation to the wound debridement procedure.
- Consider the patient's medical history, current medications, and the potential risks and benefits of holding or continuing anticoagulation therapy 3, 4, 5, 6, 7.