How Long to Hold Eliquis for Epidural Injection
For patients with normal renal function undergoing epidural injection, hold Eliquis (apixaban) for at least 48 hours (4 doses) prior to the procedure, and extend this to 72-120 hours (up to 5 days) for neuraxial procedures due to their very high hemorrhagic risk. 1
Risk Classification
Epidural injections and neuraxial anesthesia/puncture are classified as very high hemorrhagic risk procedures because:
- Spinal/epidural bleeding can cause permanent neurological damage from spinal cord compression 2
- Surgical hemostasis cannot be performed safely in the confined space of the spinal canal 1
- These procedures require complete hemostasis with no margin for error 2
Specific Hold Duration for Normal Renal Function (CrCl >50 mL/min)
The French Working Group on Perioperative Hemostasis strongly recommends holding apixaban for up to 5 days before neuraxial anesthesia/puncture in patients without renal failure. 1
For patients with normal renal function:
- Minimum hold: 48 hours (standard for high-risk procedures) 2, 3
- Recommended for neuraxial procedures: 72-120 hours (3-5 days) due to catastrophic consequences of epidural hematoma 1
- The last dose should be taken 3 days before the procedure when CrCl >30 mL/min 1
Adjustments for Renal Impairment
If creatinine clearance is reduced, extend the hold duration:
- CrCl 30-50 mL/min: Hold for 72-96 hours 2
- CrCl <30 mL/min: Consider 96-120 hours (4-5 days) and consult hematology 1, 2
- Apixaban has 27% renal elimination, making renal function critical to clearance 4
Additional Risk Factors Requiring Extended Hold
Extend the interruption period to the full 5 days if the patient has: 1
- Age ≥80 years 5
- Concomitant P-glycoprotein inhibitors (e.g., verapamil, amiodarone)
- Concomitant CYP3A4 inhibitors (e.g., ketoconazole, ritonavir)
- Body weight ≤60 kg
- Any factor suggesting drug accumulation
Critical Safety Warnings
The French Working Group strongly recommends NOT performing spinal or epidural anesthesia in patients with possible residual apixaban concentration due to insufficient discontinuation time. 1
The FDA label explicitly states:
- "Optimal timing between the administration of apixaban and neuraxial procedures is not known" 3
- Risk factors for epidural/spinal hematoma include indwelling catheters, concomitant NSAIDs/antiplatelet agents, and history of traumatic puncture 3
Bridging Anticoagulation
Do NOT use bridging anticoagulation with heparin or LMWH during the interruption period. 1
- Bridging significantly increases bleeding risk without reducing thrombotic events 2, 5
- The brief interruption period does not warrant bridging except in extremely high thrombotic risk patients 1
Resumption After Procedure
Resume apixaban at least 24-48 hours after the epidural procedure once adequate hemostasis is established. 2, 3
- For neuraxial procedures, wait 24-48 hours minimum 2
- Restart at the patient's usual maintenance dose 5
- If ongoing bleeding or surgical contraindication exists, delay resumption further 1
Common Pitfalls to Avoid
- Failing to obtain recent creatinine clearance before determining hold duration can lead to inadequate drug clearance 6
- Not accounting for the 48-hour period correctly: This means 4 full doses are skipped (2 full days of twice-daily dosing), not just holding the morning dose 5
- Performing the procedure too early in elderly patients or those on interacting medications without extending the hold period 1
- Using bridging anticoagulation unnecessarily, which increases bleeding risk 1, 2
Practical Algorithm
- Verify renal function using Cockcroft-Gault formula 1
- Check for drug interactions (P-gp or CYP3A4 inhibitors) 1
- Determine hold duration:
- Normal renal function + no risk factors: 72 hours minimum (3 days)
- Normal renal function + age >80 or drug interactions: 96-120 hours (4-5 days)
- CrCl 30-50: 72-96 hours
- CrCl <30: 96-120 hours + hematology consultation
- Do not bridge with heparin 1
- Resume 24-48 hours post-procedure once hemostasis confirmed 2, 3