How Long to Hold Eliquis Before Bone Marrow Biopsy
Hold apixaban (Eliquis) for 1 day (24 hours, or skip 2 doses) before bone marrow biopsy in patients with normal renal function, as bone marrow biopsy is classified as a low-to-moderate bleeding risk procedure. 1, 2
Bleeding Risk Classification
- Bone marrow biopsy is classified as a low-to-moderate bleeding risk procedure based on the extremely low incidence of significant hemorrhage (0.007-1.1%) reported in the literature 3
- The American College of Chest Physicians guidelines specifically recommend stopping apixaban 1 day (24 hours) before low-to-moderate bleeding risk procedures, which corresponds to approximately 2-3 half-lives and achieves minimal residual anticoagulant effect 1
Standard Discontinuation Protocol
- For patients with normal renal function (CrCl >50 mL/min): Stop apixaban 1 day before the procedure (skip 2 doses, approximately 24 hours) 1, 2
- For patients with moderate renal impairment (CrCl 30-50 mL/min): Consider extending the hold period to 2 days, though specific guidance for bone marrow biopsy is limited 1
- For patients with severe renal impairment (CrCl <30 mL/min): Consider holding for 3 days before the procedure 1
Critical Management Points
No Bridging Required
- Do not use bridging anticoagulation during the interruption period, as it increases hemorrhagic risk without reducing thrombotic events 1
- Bridging should only be considered for very high thrombotic risk patients after multidisciplinary discussion 1
Resumption After Procedure
- Restart apixaban at least 24 hours after the bone marrow biopsy once adequate hemostasis is established 1, 4
- Resume the full therapeutic dose (5 mg twice daily, or 2.5 mg twice daily if dose reduction criteria are met) 1, 4
Important Caveats
Do Not Rely on Laboratory Testing
- Do not use INR or aPTT to guide timing decisions, as apixaban's effect on these tests is inconsistent and unreliable for surgical clearance 1
- Routine measurement of apixaban concentrations is not necessary when recommended interruption periods are followed 1
Patient-Specific Risk Assessment
- While withholding anticoagulation is not routinely required for bone marrow biopsy, assessment of individual bleeding risk factors should be performed 3
- Thrombocytopenic patients have a non-negligible bleeding risk that is independent of anticoagulation status (p = 0.002 in one study) 5
- Patients with myeloproliferative neoplasms may have acquired von Willebrand syndrome, requiring extra vigilance for hemostasis 3
Coagulation Profile
- Routine coagulation profiling (PT, aPTT) appears irrelevant for predicting bleeding risk in bone marrow biopsy 5
- Platelet count is the most relevant laboratory parameter, with low platelet counts significantly associated with bleeding (p = 0.002) 5
Evidence Quality Note
The 2026 American College of Chest Physicians guidance (via Praxis Medical Insights) provides the most recent and specific recommendations for apixaban management before procedures 1, 2. This supersedes older 2014 guidelines that provided more general recommendations for direct oral anticoagulants 6. The classification of bone marrow biopsy as low-to-moderate risk is supported by retrospective studies showing no major bleeding events in large cohorts 3, 5.