Is it safe to hold Eliquis (apixaban) for a biopsy 2 months post embolic stroke?

From the Guidelines

It is not recommended to hold Eliquis for a biopsy 2 months post embolic stroke without careful consideration of the individual's stroke and bleeding risk, as the benefits of anticoagulation in preventing recurrent strokes often outweigh the risks of bleeding associated with the biopsy procedure. Patients who have experienced an embolic stroke are at high risk for recurrent strokes, especially in the early months following the initial event, and Eliquis is prescribed specifically to prevent these dangerous clotting events 1. The decision to temporarily discontinue Eliquis should be made by a healthcare provider who will carefully weigh the individual's stroke risk against bleeding risk during the procedure.

Key Considerations

• The type and location of the biopsy
• The individual's complete medical history, including any history of bleeding or clotting disorders
• The use of bridging therapy with shorter-acting anticoagulants during the perioperative period Some biopsies can be performed safely while remaining on anticoagulation, depending on the location and type of biopsy. If Eliquis must be interrupted, it would typically be held for the shortest possible time (usually 24-48 hours before the procedure) and resumed as soon as hemostasis is achieved (often within 24-72 hours after the procedure) 1. Non-pharmacological prevention strategies such as ablation or occlusion of the atrial appendage should also be considered as potential substitutes for anticoagulation therapy.

Management Approach

• Assess the individual's stroke risk and bleeding risk
• Consider alternative anticoagulation strategies, such as bridging therapy
• Develop a personalized plan for managing anticoagulation during the biopsy procedure By carefully considering these factors and developing a personalized plan, healthcare providers can minimize the risks associated with holding Eliquis for a biopsy 2 months post embolic stroke and ensure the best possible outcomes for their patients.

From the FDA Drug Label

When neuraxial anesthesia (spinal/epidural anesthesia) or spinal/epidural puncture is employed, 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 The risk of these events may be increased by the postoperative use of indwelling epidural catheters or the concomitant use of medicinal products affecting hemostasis. Indwelling epidural or intrathecal catheters should not be removed earlier than 24 hours after the last administration of apixaban tablets The next dose of apixaban tablets should not be administered earlier than 5 hours after the removal of the catheter.

It is not safe to hold apixaban for a biopsy 2 months post embolic stroke without considering the potential risks.

• The FDA drug label does not provide specific guidance on holding apixaban for a biopsy 2 months post embolic stroke.
• However, it does provide guidance on the risk of spinal/epidural hematoma with neuraxial anesthesia or puncture.
• To minimize the risk of bleeding, it is recommended to delay the administration of apixaban for 48 hours if traumatic puncture occurs.
• The decision to hold apixaban should be made on a case-by-case basis, considering the individual patient's risk factors and the potential benefits and risks of the procedure 2.

From the Research

Safety of Holding Anticoagulation for Biopsy after Embolic Stroke

• The safety of holding anticoagulation for a biopsy 2 months post embolic stroke is a complex issue that requires careful consideration of the risks and benefits.
• According to a study published in 1993 3, anticoagulation may be safely used in some patients with hemorrhagic infarction, especially when the risk of recurrent embolism is high.
• However, another study published in 2008 4 found that bridging anticoagulation with heparin or enoxaparin increased the risk of serious bleeding, including symptomatic hemorrhagic transformation.
• A more recent study published in 2020 5 suggested that anticoagulation therapy might be associated with a reduced risk of recurrent stroke compared with antiplatelet therapy in patients with embolic stroke of undetermined source.
• It is also important to consider the balance between preventing symptomatic pulmonary embolism and causing symptomatic intracerebral hemorrhage, as discussed in a study published in 2013 6.
• Ultimately, the decision to hold anticoagulation for a biopsy 2 months post embolic stroke should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.

Key Considerations

• The risk of recurrent embolism and the potential benefits of anticoagulation therapy
• The risk of bleeding and the potential consequences of holding anticoagulation
• The individual patient's medical history and risk factors, including the presence of hemorrhagic infarction or other bleeding risks
• The results of imaging studies, such as CT scans, to assess the risk of bleeding and the presence of hemorrhagic infarction

Relevant Studies

• 6: Balance of symptomatic pulmonary embolism and symptomatic intracerebral hemorrhage with low-dose anticoagulation in recent ischemic stroke
• 3: Safety of anticoagulation after hemorrhagic infarction
• 4: Anticoagulation after cardioembolic stroke: to bridge or not to bridge?
• 5: Anticoagulation and Risk of Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source Having No Potential Source of Embolism