Should apixaban (Eliquis) be stopped prior to a spinal or epidural steroid injection for back pain?

Should Apixaban (Eliquis) Be Stopped for Spinal/Epidural Steroid Injection?

Yes, apixaban must be stopped for at least 48-72 hours before any spinal or epidural steroid injection due to the catastrophic risk of spinal epidural hematoma, which can cause permanent paralysis. 1, 2, 3

Critical Safety Warning

Neuraxial procedures (spinal/epidural injections) carry a uniquely high risk of catastrophic bleeding complications because even small hematomas in the spinal canal can cause irreversible paralysis. 3 The FDA label for apixaban explicitly warns that "patients treated with antithrombotic agents for prevention of thromboembolic complications are at risk of developing an epidural or spinal hematoma which can result in long-term or permanent paralysis." 3

Specific Timing for Discontinuation

For patients with normal renal function (CrCl >30 mL/min):

• Stop apixaban 48 hours before the epidural steroid injection 2, 3
• The American College of Chest Physicians recommends 72 hours of discontinuation for neuraxial procedures to ensure >98% drug elimination 2

For patients with renal impairment or age >80 years:

• Extend the interruption period to 72-96 hours or up to 5 days in patients with additional risk factors 2, 4

The Association of Anaesthetists guidelines specify that apixaban should be stopped 24-48 hours for prophylactic dosing, but this applies to general procedures—not neuraxial interventions, which require longer interruption. 1

Why Bridging Is Dangerous and Not Recommended

Do not use bridging anticoagulation with heparin or low-molecular-weight heparin when stopping apixaban. 5, 2, 4 Bridging significantly increases bleeding risk without reducing thrombotic events. 1, 2 The American Society of Anesthesiologists explicitly states that bridging with heparin products when stopping DOACs increases bleeding risk and is not recommended. 5

Catheter Management (If Applicable)

If an epidural catheter is placed:

• The catheter should not be removed earlier than 24 hours after the last dose of apixaban 3
• The next dose of apixaban should not be given earlier than 5 hours after catheter removal 3
• Wait at least 2 hours after catheter removal before administering the first dose of apixaban 2

When to Resume Apixaban After the Injection

• Resume apixaban at least 24-48 hours after the procedure once adequate hemostasis is established 5, 2, 4
• For high bleeding risk procedures (which includes neuraxial injections), delay resumption for 48-72 hours until hemostasis is secure 5
• The FDA label states apixaban should be restarted "as soon as adequate hemostasis has been established" 3

Critical Pitfalls to Avoid

Never perform the epidural injection if there is any possibility of residual apixaban levels, particularly in elderly patients (>80 years) or those with renal impairment. 5, 2 The pharmacodynamic effect of apixaban persists for at least 24 hours after the last dose (approximately two drug half-lives). 3

Do not use INR or aPTT to monitor apixaban activity—these tests do not reliably reflect anticoagulant effect from DOACs. 2 If there is uncertainty about drug clearance, consider measuring anti-factor Xa levels, though this is not routinely available. 1

If traumatic puncture occurs during the procedure, delay administration of apixaban for 48 hours. 1, 3

Evidence Quality and Nuances

While one retrospective study of 392 caudal epidural injections found no complications in patients remaining on antithrombotics 6, this contradicts all major society guidelines and the FDA label. 1, 2, 3 The catastrophic nature of spinal hematoma (permanent paralysis) means even a very low risk is unacceptable when the medication can be safely interrupted. Case reports document spontaneous spinal epidural hematomas in patients on apixaban 7, and at least one case of epidural hematoma occurred despite strict adherence to anticoagulation guidelines. 8

The American Society of Regional Anesthesia guidelines, FDA labeling, and multiple international anesthesia societies all agree that apixaban must be stopped for neuraxial procedures. 1, 2, 3 The single contradictory study 6 used only the caudal approach (lowest risk epidural route) and had 51 encounters lost to follow-up, limiting its reliability.

Monitoring After the Procedure

Monitor patients frequently for signs of neurological impairment including numbness, weakness of the legs, or bowel/bladder dysfunction. 3 If neurological compromise is noted, urgent diagnosis and treatment (emergency surgical decompression) is necessary. 3