Holding Eliquis (Apixaban) Prior to Epidural Procedures

Procedure Risk Classification

• Epidural anesthesia and neuraxial punctures are classified as very high hemorrhagic risk procedures that require the longest interruption time for direct oral anticoagulants (DOACs), according to the French Working Group on Perioperative Hemostasis 1

Specific Timing for Apixaban Discontinuation

• The American Society of Anesthesiologists recommends holding apixaban for 3 days (72 hours) before the epidural procedure in patients with creatinine clearance >30 mL/min, to ensure complete drug elimination and minimize hemorrhagic risk 1
• For patients with additional risk factors, consider holding apixaban for up to 5 days before the neuraxial procedure, as recommended by the French Working Group on Perioperative Hemostasis 1

Critical Safety Warnings

• The American College of Cardiology emphasizes that spinal or epidural anesthesia should never be performed if there is any possible residual DOAC concentration, particularly in patients with renal impairment 1
• Patients over 80 years of age on any DOAC, such as apixaban, require special consideration due to increased risk of bleeding complications 2

No Bridging Required

• The American Heart Association recommends not using bridging anticoagulation with heparin or low-molecular-weight heparin (LMWH) when stopping apixaban, as it increases bleeding risk without reducing thrombotic risk 2

Resumption After Epidural Procedure

• The European Society of Cardiology suggests resuming apixaban 6-48 hours after the procedure, depending on bleeding risk and adequacy of hemostasis 2
• If an epidural catheter remains in place, wait at least 2 hours after catheter removal before administering the first dose of any anticoagulant, including apixaban 4

Pharmacokinetic Rationale

• Apixaban has a half-life of approximately 12 hours, and the 72-hour hold time allows for approximately 6 half-lives to elapse, ensuring >98% drug elimination before the high-risk neuraxial procedure, as recommended by the International Anesthesia Research Society 1