What are the guidelines for stopping Eliquis (apixaban) prior to joint injection?

From the Guidelines

For joint injections, it's generally recommended to stop Eliquis (apixaban) approximately 24-48 hours before the procedure, depending on the bleeding risk of the specific injection and your individual risk factors, as supported by the findings of the PAUSE trial 1. When considering the interruption of apixaban for joint injections, several factors come into play, including the patient's kidney function, age, and other bleeding risk factors.

• For low-risk joint injections, stopping Eliquis 24 hours before (skip 2 doses) is often sufficient, while higher-risk injections may require 48 hours (skip 4 doses) 1.
• The specific timing should be individualized based on your kidney function, with considerations for creatinine clearance (CrCl) levels, as outlined in the guidelines for patients on dabigatran 1.
• Resume Eliquis approximately 24 hours after the procedure if adequate hemostasis has been achieved, allowing the anticoagulant effect to diminish sufficiently to reduce bleeding risk during the procedure.
• It's crucial to consult with both the physician performing the injection and the doctor who prescribed your Eliquis before making any changes to your medication schedule, especially for patients with high thrombotic risk (such as recent stroke, mechanical heart valve, or recent venous thromboembolism) who may need bridging therapy with shorter-acting anticoagulants during this interruption period 1.
• The most recent guidelines suggest that for patients on apixaban, the last dose should be taken 2-3 days before a high-risk procedure, with adjustments made based on renal function 1.

From the FDA Drug Label

2.3 Temporary Interruption for Surgery and Other Interventions 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 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.

The guidelines for stopping apixaban (Elequis) for joint injection are to discontinue the medication at least 48 hours prior to the procedure if it has a moderate or high risk of bleeding, or at least 24 hours prior if it has a low risk of bleeding. Apixaban tablets should be restarted after the procedure as soon as adequate hemostasis has been established 2.

From the Research

Guidelines for Stopping Eliquis for Joint Injection

• The American Society of Interventional Pain Physicians (ASIPP) guidelines suggest that discontinuation of anticoagulant therapy with apixaban (Eliquis) prior to interventional techniques increases safety, with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors 3.
• There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran, argatroban, bivalirudin, lepirudin, desirudin, hirudin, apixaban, rivaroxaban, edoxaban, betrixaban, and fondaparinux prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety 3.
• A study published in the Mayo Clinic proceedings found that arthrocentesis and joint injections in patients receiving direct oral anticoagulants (DOACs), including apixaban, are safe procedures, and there is no need to withhold anticoagulation treatment before the procedure 4.
• Another study found that patients who received a factor Xa inhibitor, such as apixaban, experienced a lower risk of composite major and clinically relevant nonmajor bleeding events compared with unfractionated heparin (UFH) in patients with acute kidney injury (AKI) 5.
• A systematic review and meta-analysis found that apixaban was favored over warfarin for treating venous thromboembolism (VTE) in severe renal failure, reducing VTE recurrence and bleeding risk 6.
• A review of the safety and efficacy of apixaban in patients with severe renal impairment found that multiple studies suggest that apixaban is possibly associated with a lower prevalence of bleeding and thromboembolic events compared with warfarin therapy in patients with end-stage renal disease (ESRD) and can be safely initiated in those within this sub-group who require anticoagulation with a DOAC 7.

Key Considerations

• The decision to stop Eliquis for joint injection should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
• The ASIPP guidelines recommend considering the pharmacokinetics and pharmacodynamics of the drug, as well as the individual risk factors, when deciding whether to discontinue anticoagulant therapy prior to interventional techniques.
• The available evidence suggests that apixaban can be safely continued in patients undergoing joint injection, but the decision to do so should be made in consultation with the patient's healthcare provider.