How long should Eliquis (apixaban) be held before a thyroid fine-needle aspiration (FNA) biopsy in a patient with atrial fibrillation?

Thyroid FNA and Eliquis Management

For a thyroid fine-needle aspiration (FNA) biopsy, you do not need to hold Eliquis (apixaban) at all, as this is a low bleeding risk procedure that can be safely performed on continuous anticoagulation. 1

Bleeding Risk Classification

• Thyroid FNA is classified as a low/minimal bleeding risk procedure where anticoagulation does not need to be modified 1
• The procedure involves minimal tissue trauma with easily compressible anatomy, making it safe to perform without interrupting anticoagulation 1

Guideline Recommendations

• The ACC/AHA/HRS guidelines explicitly state that anticoagulation should not be interrupted for minor procedures with minimal bleeding risk 2, 1
• The ESC 2024 guidelines similarly recommend continuing oral anticoagulation for low-risk procedures 2
• For procedures requiring only minimal tissue manipulation where bleeding would be easily controlled, DOACs like apixaban can be safely continued 2

Clinical Approach

Continue apixaban at the patient's regular dose through the thyroid FNA procedure without any interruption 1

Key Management Points:

• No dose adjustment or timing changes are needed for the FNA 1
• The patient should take their regular apixaban dose (either 5 mg or 2.5 mg twice daily, depending on their indication) on the day of the procedure 3
• Apply local pressure post-procedure as standard practice to ensure hemostasis 1

Important Considerations

• Unnecessarily interrupting anticoagulation exposes this atrial fibrillation patient to increased stroke risk that far outweighs any minimal bleeding risk from thyroid FNA 1
• The patient's CHA₂DS₂-VASc score should guide the importance of maintaining anticoagulation—higher scores make continuous anticoagulation even more critical 2
• Bridging therapy is absolutely not indicated for this low-risk procedure 2, 3

Common Pitfalls to Avoid

• Do not hold apixaban "just to be safe"—this actually increases net harm by raising thromboembolic risk without meaningful reduction in bleeding complications 1
• Do not confuse thyroid FNA with higher-risk thyroid procedures (such as thyroid surgery or core needle biopsy), which would require different management 2
• Avoid relying on INR or aPTT to assess apixaban effect, as these tests are insensitive to DOACs and provide no useful clinical information 4