In an adult with normal renal function (creatinine clearance >30 mL/min) and no additional high‑bleeding‑risk factors, how long should apixaban (Eliquis) be held before posterior nasal‑nerve neurolysis?

Apixaban Hold Duration for Posterior Nasal Nerve Neurolysis

For an adult with normal renal function undergoing posterior nasal nerve neurolysis, hold apixaban (Eliquis) for 2 days (48 hours) before the procedure. 1

Bleeding Risk Classification

Posterior nasal nerve neurolysis should be classified as a high bleeding risk procedure because:

• The nasal cavity is highly vascular with limited ability to achieve surgical hemostasis 1
• Bleeding in this confined space can compromise the airway and is difficult to control 1
• The procedure involves tissue manipulation in an area where even minor bleeding can have significant clinical consequences 1

Specific Hold Protocol

For Normal Renal Function (CrCl >30 mL/min)

Hold apixaban for 2 full days before the procedure. 1 This means:

• If the patient takes apixaban at 8 PM and surgery is scheduled for 8 AM two days later, the last dose is taken 60 hours before the procedure 1
• The patient does not take apixaban on the day of surgery 1
• Count backward 2 full days from the procedure date to determine when to stop 1

For Impaired Renal Function

If CrCl is 25-30 mL/min, consider extending the hold period to 3 days due to slower drug clearance and prolonged half-life. 1

Critical Pre-Procedure Requirements

Before determining the exact hold duration, you must:

• Obtain recent creatinine clearance using the Cockcroft-Gault formula, as apixaban has approximately 27% renal elimination 1, 2, 3
• Review all concomitant medications for combined P-glycoprotein and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir), which may require extending the hold period 2, 1
• Verify the patient's current apixaban dose (5 mg vs 2.5 mg twice daily), though the hold duration remains the same regardless of dose 1

Bridging Anticoagulation

Do not use bridging therapy with heparin or low-molecular-weight heparin. 1, 4 Bridging is:

• Not recommended for DOAC interruption 1, 4
• Increases bleeding risk without proven benefit 1, 4
• Unnecessary given the predictable pharmacokinetics of apixaban 1, 4

Resumption After Procedure

Resume apixaban at least 48-72 hours after the procedure, provided that: 1, 4, 5

• Adequate hemostasis has been established 1, 4, 5
• There is no ongoing bleeding 1, 4, 5
• No surgical contraindication exists 1, 4, 5

If bleeding persists or surgical concerns remain, delay resumption and consider mechanical or pharmacologic venous thromboprophylaxis based on the patient's thromboembolic risk. 1

Common Pitfalls to Avoid

Pitfall #1: Treating This as Low-Risk

Never hold apixaban for only 1 day (24 hours) for this procedure. 1 The 1-day hold is reserved for truly low bleeding risk procedures where hemostasis is easily achieved (e.g., dental extractions, cataract surgery). 1, 6 Nasal procedures involving neurolysis have significantly higher bleeding risk. 1

Pitfall #2: Inadequate Renal Assessment

Failing to check renal function before determining hold duration can lead to inadequate drug clearance. 1, 2, 3 Even mild renal impairment (CrCl 50-80 mL/min) increases apixaban exposure by approximately 16%, and severe impairment (CrCl 15-29 mL/min) increases it by 44%. 3

Pitfall #3: Unnecessary Bridging

Using bridging anticoagulation increases bleeding complications without reducing thrombotic events. 1, 4 The PAUSE study demonstrated that a simple interruption strategy based on pharmacokinetics is safe and effective. 1

Pitfall #4: Premature Resumption

Restarting apixaban before 48 hours post-procedure significantly increases bleeding risk. 1, 4, 5 The nasal mucosa requires adequate time for hemostatic plug formation and tissue healing. 1, 4, 5

Evidence Quality and Nuances

The 2-day hold recommendation comes from the 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline, which represents the most recent and authoritative guidance. 1 This guideline explicitly categorizes procedures by bleeding risk and provides clear discontinuation timelines. 1

The 2021 ACC Expert Consensus provides additional granular detail for specific procedural contexts, though it focuses primarily on PCI rather than ENT procedures. 1 The French GIHP guidelines offer a more conservative approach for very high-risk procedures (5-day hold), but this is typically reserved for intracranial neurosurgery or neuraxial anesthesia. 1

Research data from the ADIOS study confirms that 48-hour discontinuation achieves clinically insignificant apixaban concentrations (≤30 ng/mL) in 94% of patients. 7 This provides real-world validation of the guideline recommendations. 7