What is the recommended management of apixaban (direct oral anticoagulant) in a patient with normal kidney function and a history of bleeding or thromboembolism undergoing nasal intubation?

Apixaban Management for Nasal Intubation

For nasal intubation in a patient with normal renal function on apixaban, hold the medication for 3 days (72 hours) before the procedure, with the last dose taken on the morning 3 days prior to intubation. 1, 2

Rationale for 3-Day Discontinuation

Nasal intubation is classified as a high bleeding risk procedure requiring complete drug clearance because:

• Neuraxial and airway procedures carry catastrophic bleeding risk - the highly vascular nasal mucosa and proximity to critical structures (including potential for epidural hematoma if neuraxial anesthesia is used) necessitate minimal residual anticoagulation 1, 2

• The 3-day window allows 4-5 half-lives to elapse - with apixaban's half-life of 7-8 hours in normal renal function, 72 hours provides approximately 9-10 half-lives, ensuring minimal (≤6%) residual anticoagulant effect 1, 3

• No reversal agent is readily available - unlike warfarin, apixaban lacks a reliable immediate reversal option, making adequate pre-procedure clearance essential 2, 4

Specific Timing Protocol

For patients with normal renal function (CrCl ≥50 mL/min):

• Last apixaban dose: 3 days before procedure (skip 4 doses if twice-daily regimen) 1
• If taking apixaban 5 mg twice daily: last dose on morning of Day -3 1
• If taking apixaban once daily (morning): last dose on morning of Day -3 1

For patients with moderate renal impairment (CrCl 30-50 mL/min):

• Last apixaban dose: 4 days before procedure (skip 6 doses if twice-daily regimen) 1
• The prolonged elimination half-life (up to 12 hours) in renal impairment requires extended clearance time 3

Critical Considerations for High-Risk Patients

If the patient has a history of thromboembolism or recent arterial event:

• The 3-day interruption creates a critical window of vulnerability, as apixaban provides no anticoagulation protection after 48-72 hours 5
• Do NOT use bridging anticoagulation with heparin - bridging increases bleeding risk without reducing thrombotic events in this timeframe 1, 2
• Consider whether the nasal intubation is truly necessary or if alternative approaches exist 5

If the patient has a history of bleeding:

• The 3-day discontinuation is still required - underdosing or shorter interruption does not reduce procedural bleeding risk and may paradoxically increase it 1
• History of minor bleeding is often cited as rationale for inappropriate underdosing, but this does not change the pharmacokinetic requirements for safe surgery 1

Postoperative Resumption

Resume apixaban 48-72 hours after nasal intubation once adequate hemostasis is confirmed:

• For high bleeding risk procedures like nasal intubation, wait 2-3 days postoperatively before restarting 1
• Start with full therapeutic dose (5 mg twice daily) - do not use reduced dosing unless specific dose-reduction criteria are met (age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL, with at least 2 of 3 criteria present) 3
• Apixaban achieves therapeutic effect rapidly, so bridging is unnecessary 2

Major Pitfalls to Avoid

• Do not perform nasal intubation with insufficient discontinuation time - the French Working Group strongly recommends against airway procedures in patients with possible residual DOAC concentration 1

• Do not rely on INR or aPTT to guide timing - these tests are inconsistent for apixaban and should not be used for surgical clearance 2

• Do not use bridging anticoagulation - this increases bleeding risk without benefit in the 48-72 hour perioperative window 1, 2

• Verify recent renal function before determining timing - creatinine clearance directly impacts elimination and must be calculated using Cockcroft-Gault formula 1, 3