Eliquis (Apixaban) Washout Time Before Heart Catheterization
For elective heart catheterization, hold apixaban for 24 hours (skip 2 doses) if using transradial access with normal renal function (CrCl ≥30 mL/min), or 48 hours (skip 4 doses) if using transfemoral access. 1
Transradial Approach (Preferred Access)
Normal Renal Function (CrCl ≥30 mL/min):
- Hold apixaban for ≥24 hours before procedure 1
- This corresponds to skipping 2 doses 1
- Last dose should be taken the morning of the day before the procedure 1
Impaired Renal Function (CrCl 15-29 mL/min):
- Hold apixaban for ≥36 hours before procedure 1
- Longer washout needed due to reduced renal clearance (27% of apixaban is renally cleared) 2
Severe Renal Impairment (CrCl <15 mL/min):
- Hold for ≥48 hours or guide duration by agent-specific anti-Xa level 1
Transfemoral Approach
Normal Renal Function (CrCl ≥30 mL/min):
- Hold apixaban for ≥48 hours before procedure 1
- This corresponds to skipping 4 doses 1
- Longer washout required due to higher bleeding risk with femoral access 1
Impaired Renal Function (CrCl <29 mL/min):
- Hold for ≥72 hours or guide duration by agent-specific anti-Xa level 1
Key Clinical Considerations
Apixaban Pharmacokinetics:
- Half-life is 12 hours (range 10-15 hours) 1
- The 24-48 hour washout period allows for 2-4 half-lives to elapse, achieving minimal residual anticoagulant effect 1
- Real-world data confirms that 48+ hours of discontinuation results in clinically insignificant anticoagulation (94% of patients achieved levels ≤30 ng/mL) 3
No Bridging Required:
- Do not bridge with parenteral anticoagulation (LMWH or heparin) during the washout period 1
- The predictable short half-life of apixaban makes bridging unnecessary and increases bleeding risk 1
- Bridging is only considered for patients presenting with acute coronary syndrome, not stable elective cases 1
Emergency Situations:
- For STEMI or high-risk NSTEMI, stop apixaban immediately and proceed with PCI without delay 1
- Activated clotting time (ACT) is not a reliable indicator of apixaban anticoagulation during emergency procedures 1
- Consider reversal with andexanet alfa for life-threatening bleeding 4
Common Pitfalls to Avoid
Drug Interactions:
- Patients taking concomitant P-gp inhibitors (dronedarone, amiodarone, verapamil) may need an additional 24 hours of washout 1
- These medications prolong apixaban clearance and increase bleeding risk 1
Renal Function Assessment:
- Always calculate creatinine clearance before determining washout duration 1, 2
- Moderate renal impairment significantly prolongs apixaban elimination 2
- Do not rely on serum creatinine alone 1
Timing Errors:
- The FDA label states apixaban should be discontinued at least 48 hours prior to elective surgery with moderate-to-high bleeding risk 5
- However, the 2021 ACC guidelines provide more nuanced, access-specific recommendations that allow for 24-hour washout with radial access 1
- Use the access-specific approach from the most recent ACC guidelines rather than the blanket FDA recommendation 1
Unreliable Laboratory Monitoring:
- Do not use INR or aPTT to guide timing, as apixaban's effect on these tests is inconsistent 2
- If measurement is needed, use agent-specific anti-Xa levels 1
Postprocedural Resumption
- Resume apixaban ≥24 hours after low bleeding risk procedures once adequate hemostasis is established 1, 5
- For high bleeding risk procedures or complications, consider resuming at 48-72 hours postprocedure 1
- No loading dose is required due to rapid onset of action 1