From the Guidelines
Apixaban should typically be stopped 48 hours (2 days) before PEG tube insertion for patients with normal renal function, as supported by the most recent and highest quality study 1. This recommendation is based on the study published in 2022, which assessed the perioperative management of antithrombotic therapy and found that interrupting apixaban for 1 to 2 days before a surgery/procedure was associated with low rates of major bleeding and arterial thromboembolism. For patients with impaired kidney function, the duration of apixaban interruption may need to be extended, up to 3-4 days before the procedure, as suggested by earlier studies 1. However, the 2022 study 1 provides the most recent and highest quality evidence, and its findings should be prioritized in clinical decision-making. After the PEG tube placement, apixaban can usually be resumed 24-48 hours later, once adequate hemostasis has been achieved and the risk of bleeding has decreased. It is essential to consult with a healthcare provider before making any changes to the medication regimen, as they may recommend a specific plan based on individual risk factors for both bleeding and thrombosis. Some patients at high risk for thrombosis may be bridged with a shorter-acting anticoagulant during this period. Key points to consider include:
- Apixaban interruption duration: 2 days for patients with normal renal function
- Extended interruption for impaired kidney function: up to 3-4 days
- Resumption of apixaban: 24-48 hours after PEG tube placement
- Importance of consulting a healthcare provider for individualized management
- Potential need for bridging with a shorter-acting anticoagulant in high-risk patients.
From the FDA Drug Label
Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.
The recommended duration to stop apixaban before a procedure like PEG tube insertion is not explicitly stated, but based on the information provided for other procedures, it is likely that apixaban should be discontinued at least 24 hours prior to the procedure, considering PEG tube insertion is generally a procedure with a low to moderate risk of bleeding. 2
From the Research
Stopping Apixaban for PEG Tube Insertion
- The provided studies do not directly address the duration for which apixaban should be stopped before a PEG tube insertion.
- However, it is known that apixaban is a direct oral anticoagulant (DOAC) that directly inhibits factor II or factor Xa, providing more immediate anticoagulation 3.
- The management of anticoagulation therapy, including the cessation of DOACs like apixaban before procedures, is crucial to balance the risk of thromboembolism and bleeding.
- For patients undergoing procedures that carry a risk of bleeding, such as PEG tube insertion, the decision to stop anticoagulation therapy and for how long should be made on an individual basis, considering the patient's risk factors for both thromboembolism and bleeding.
- There is evidence suggesting that the risk of bleeding in patients undergoing PEG tube insertion while on antiplatelet therapy is not significantly increased, but this does not directly translate to the use of anticoagulants like apixaban 4.
- Given the lack of direct evidence, clinical guidelines and the specific clinical context of the patient should guide the decision on when to stop apixaban before a PEG tube insertion.
- It is essential to consult the latest clinical guidelines and consider the patient's individual risk factors when making this decision.